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1 



CONTRIBUTIONS 



TO 



PRACTICAL SURGERY. 



CONTRIBUTIONS 



TO 



PRACTICAL SURGERY. 




GEORGE W. MORRIS, M.D., 



LATE SURGEON TO THE PENNSYLVANIA HOSPITAL ; YICE-PRESIDENT OF THE 

COLLEGE OP PHYSICIANS OF PHILADELPHIA, MEMBER OF THE 

SOCIETE MEDICALE d'OBSERVATION OF PARIS, ETC. 



D 




PHILADELPHIA: £ 
LINDSAY AID BLAKISTON. 
18*73. 




Entered according to Act of Congress, in the year 1873, by 

GEORGE W. NORRIS, M.D., 
in the Office of Librarian of Congress. All rights reserved. 



PHILADELPHIA: 
COLLINS, PRINTER, 

705 Jayne Street. 



PREFACE. 



Several of the following essays appeared originally in 
the American Journal of the Medical Sciences. Those upon 
the occurrence of Non-union after Fractures, and the Statisti- 
cal Eesults of Operations upon the larger Arteries, and upon 
Fractures and Amputations, have met with favorable notice 
abroad as well as at home, and have been freely made use of 
by later writers, in some instances with but slight notice 
of their sources. The statistical method of investigation at 
the time of their publication was something of a novelty 
in surgery, and was looked upon with suspicion, but it is now 
everywhere accepted as one of value in all departments of 
research. Much labor was expended in the collection of 
these statistics and in their careful analysis. They are now 
reprinted for reference and comparison with more recent 
investigations. 

There have been added a paper on Compound Fractures, a 
large amount of new material on the Occurrence of False 
Joints, and numerous Clinical Histories drawn from a hospital 
service of thirty years, which, it is hoped, may not prove 
uninteresting to the practitioner. 

1534 Locust St., Philadelphia, 
July 1st, 1873. 



TABLE OF CONTENTS. 



PAGE 

On the Occurrence of Non-union after Fractures . . 9 

On the Treatment of Deformities Following Unsuccess- 
fully Treated Fractures 112 

Statistics of Fractures and Dislocations Treated in the 
Pennsylvania Hospital during the Twenty 
Years from 1830 to 1850 132 

On Compound Fractures . . . . . . .164 

Statistical Account of the Cases of Amputation Per- 
formed at the Pennsylvania Hospital from 
Jan. 1, 1850, to Jan. 1, 1860. 
With a general summary of the mortality following this 

operation in that institution for thirty years . .210 

Statistics of the Mortality following the Ligature of 

Arteries 220 

I. Mortality following the Operation of Tying the 

Subclavian Artery 222 

II. Mortality following the Operation of Tj'ing the Iliac 

Arteries 234 

III. Mortality following the Operation of Tying the 

Carotid Arteries and Arteria Innominata . .251 

IV. Mortality following the Operation of Tying the 

Femoral Arteiy 285 

Yaricose Aneurism at the bend of the Arm . . .314 



CONTRIBUTIONS 



TO 



PRACTICAL SURGERY. 



ON THE OCCURRENCE OF NON-UNION AFTER FRACTURES- 
ITS CAUSES AND TREATMENT. 

Few subjects in surgery possess so much interest and import- 
ance, or have more justly exercised the pens of writers, than 
injuries to the bones with their consequences, and yet we find 
at this day many points in relation to them demanding further 
investigation. Of this kind, is that state of parts following 
upon a solution of continuity in the bony structure, termed un- 
united fracture, the causes, pathology, treatment, etc., of which, 
are all matters upon which very indefinite ideas are held by the 
great mass of practitioners. Having had my attention particu- 
larly drawn to the subject, and finding the great contrariety of 
opinion that existed among writers and practitioners in regard 
to the best mode of treatment of this state of parts, I collected 
together a table of as many of the more complete cases as I 
found recorded in the works within my reach, with a view to 
their analysis, for the purpose of satisfying myself on this im- 
portant point. 

The tables, together with the analysis made of them, have 
been very carefully drawn out, and believing them to possess 
interest, I have ventured to arrange them for publication, in 
connection with other matter on the subject with which their 
analysis, and my reading and personal observations, have fur- 
nished me. The single cases which at long intervals meet the 
2 



10 CONTRIBUTIONS TO PRACTICAL SURGERY. 

eye of the reader, like the results of treatment given by prac- 
titioners from recollection alone, not unfrequently mislead us, 
and I am inclined to think, were the scattered facts which we 
find recorded in our science more frequently collected together 
in tabular forms, compared, and analyzed, that we would be 
furnished with much valuable information of which we are now 
deprived. I am well aware that many objections hava been 
urged to this mode of arriving at conclusions. In surgery, un- 
happily, we are all too prone to silence in regard to our unfortu- 
nate cases, while it is rare that success after any operation at 
all out of the common course is not made known. This forms 
the ground of the most weighty of the objections that can be 
brought against the mode of arriving at results which we have 
followed, as, by any table of published cases of any particular 
treatment that may be drawn out, the conclusions furnished 
will be much too favorable, in consequence of the fortunate 
cases only (generally speaking) being found recorded. We 
acknowledge this objection to have weight, but nevertheless 
look upon even an approach to certain results as of some value, 
and regard the method employed, when cautiously done, as one 
of the modes by which sure improvement in our science is to 
be made. 

At the period at which fractured bones become solid under 
ordinary circumstances, it sometimes happens that the frag- 
ments, though united, are not firm. Where this want of firm- 
ness exists, the consolidation is said to be delayed ; and when 
this condition is present, and the deposit of bony matter has 
been hindered by a low state of system, syphilis, scurvy, or 
other like cause, a continuance of the ordinary treatment to- 
gether with the use of appropriate remedies for the removal of 
the general affection which has retarded it, will usually be suffi- 
cient to effect a cure. When the deficiency of solidity at this 
stage is due to the want of appropriate treatment, to the too 
early use of the limb, or to improper movements of the patient 
during treatment, success from the persevering employment of 
the usual means may also be expected, but, when there is an 
absolute want of callus, or when the states first indicated have 
been overlooked or not attended to, and complete absorption of 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 11 

that first deposited has taken place, a true ununited fracture . 
may be said to exist. These states, as seen in practice, so run 
into each other, as to make it often impossible to define with 
accuracy the exact time at which the fracture may be properly 
defined to be a disunited one. The lapse of time alone does 
not indicate it, for sometimes, even after the want of solidity 
has existed for several months, the deposit of new matter to a 
greater or less extent about the seat of injury exists, and bony 
union will ultimately occur without any operative aid. 

In the observations which ensue, though simple delayed con- 
solidations will necessarily be often alluded to, yet it is true 
ununited fractures, those which have failed to unite by bone, 
under a persevering use of a proper treatment, that are more 
especially referred to. 

As a general rule, fractured bones unite readily ; and it may 
be safely averred that the occurrence of false joint after these 
accidents is not common. In his paper on the use of vesica- 
tories in this state of parts, Mr. Walker, of Oxford, 1 affirms that 
he has attended the reduction and after-treatment of not less 
than one thousand fractures, including simple and compound, 
and want of union is so rare an occurrence that he does not 
recollect more than six or eight instances of it. Monfalgon in- 
forms us 2 that during a term of six years, passed as interne and 
surgeon to one of the largest hospitals of Europe, that of Lyons, 
he met with but one case of non-consolidation after fracture. 
According to Lonsdale, 3 not more than five or six cases of false 
joint (except those within a capsule) have occurred out of nearly 
four thousand fractures treated at the Middlesex Hospital ; and 
Sir Stephen Hammick, 4 whose experience at the Plymouth 
Hospital was extensive, asserts, that he never discharged from 
that institution more than three patients with the bones not 
united. Of the great number of fractures that must have fallen 
under the notice of Mr. Liston, 5 it happened but in one instance 

1 Lond. Med. and Phys. Joum., xxxii., 1815. 

2 Mems. sur Tetat actuel de la Chirurgie, Paris, 1816. 

3 On Fractures, p. 89. 

4 Practical Remarks on Amputations, Fractures, etc., p. 122, 1830. 
6 Lancet, ii. p. 168, 1835-6. 



12 CONTBIBUTIONS TO PRACTICAL SURGERY. 

that the bones did not unite. Out of a very carefully pre- 
pared table of three hundred and sixty-seven cases of fracture 
furnished by Dr. Peirson, 1 but a single one is stated to have 
terminated in artificial joint; and by an Edinburgh writer it 
is affirmed that cases of non-union are so unfrequent, that it 
is regarded in that city as a curiosity almost to see them. 
The writer of the article "Fracture," in the Cyclopaedia of 
Practical Surgery, says, "that in the Eichmond Hospital, 
during a term of six years he has had but one case of false 
joint" (1842, p. 87), and Mr. Stanley remarks, that "in an ex- 
perience of sixteen years, in the largest hospital in London, 
either among his own cases of fracture, or in hundreds of 
others under Mr. Lawrence, he did not recollect a single case 
of ordinary fracture treated in hospital which did not turn out 
favorably. The cases of ununited fractures which he wished 
to speak about had come into hospital as such, and in too 
many instances seemed all but incurable." 2 In Philadelphia 
they are of rare occurrence; at the Pennsylvania Hospital, 
where between the years 1830 and 1840 nine hundred and 
forty-six cases of recent fracture were received, no instance of 
non-union followed the treatment pursued; all the cases ob- 
served there during that time (thirteen in number), having 
been sent to the institution from distant parts. 3 In a further 
period of ten years, at the same hospital, from 1840 to 1850, 
twelve hundred and forty-nine cases of recent fracture were 
admitted, and in no one instance did false joint follow the 
treatment. The five cases of ununited fractures treated dur- 
ing that time were all admitted as such. 4 The only writer 
known to me who holds an opinion contrary to that here ad- 
vanced is Mr. Amesbury ; he asserts, 5 that fractures of long 
standing "are by no means uncommon," and furnishes his per- 
sonal experience in fifty-six cases of this kind — a number 
much greater than any one surgeon has ever before had an 

1 Remarks on Fractures, Boston, 1840. 

2 Amer. Journ. Med. Sci., 1854, p. 548. 

3 Norris, Am. Journ. of Med. Sci., vol. i., N. S., 1841. 

4 Norris, Am. Journ. of Med. Sci., vol. xxiv., 1852, N. S., p. 301. 

5 Observations on Fractures of Long Standing, p. 195. London, 1829. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 13 

opportunity of witnessing. We are at a loss to account for 
its frequency in his practice, but a reviewer of his own nation 
observes of his statement, that the surgery of fractures must 
be singularly bad, where one individual has had occasion to 
number fifty-six examples of non-union, even making allow- 
ance for the fact, that all the bad cases came to Mr. A. alone. 1 
Setting aside, however, the positive knowledge arrived at by 
an appeal to figures, we think it evident that the generality of 
surgeons do not find it of very common occurrence, from the 
little attention that has been bestowed upon the affection, 
and the comparatively few cases to be found reported in our 
journals. 

To understand well the mechanism of false or artificial 
joints, and judge of the proper adaptation of the different 
methods recommended for their cure, a knowledge of the 
changes that take place in the natural process of reparation of 
fractured bones is requisite, and we shall preface our remarks 
on the immediate subject of this paper, by a concise account 
of the formation of callus. 

By the ancients, the union of bones after fracture was attri- 
buted to the exudation of a viscous fluid from their surfaces, 
called the osseous juice, which gradually acquired consist- 
ence, and joined firmly together the ends of the broken bone, 
in the same manner as glue would unite two pieces of wood. 
This theorv of the mode of union continued to be taught till 
towards the middle of the eighteenth century, when it was 
overthrown by the experiments of Duhamel. Comparing the 
periosteum to the bark of trees, Duhamel held that the callus 
was produced by the elongation and swelling of this mem- 
brane, either alone, or together with that lining the medullary 
canal, uniting themselves to the same parts in the opposite 
fragments. He then supposed that ossification occurred, from 
which resulted the formation of two bands or supports, one 
internal, and the other external, placed between the different 
membranes and the fragments to which they adhered, and 
extending from one to the other, in such a way as to maintain 

1 Edin. Med. and Surg. Journ., xxxi., 1829. 



1 



I'll! ill 



14 CONTRIBUTIONS TO PRACTICAL SURGERY. 

them closely in contact. In conjunction with his pupil 
Dethleef, Haller performed a number of experiments on the 
formation of callus, the result of which was an opinion con- 
trary to that advanced by Duhamel. He totally discards the 
idea that the periosteum in any way contributed to the re- 
establishment of the continuity of the broken bone, and 
believed the callus to be a jelly-like fluid produced by the 
fractured surface of the bones, and of the marrow, which 
gradually became organized and passed through a cartilaginous 
to a bony state. Bordenave carefully repeated the experi- 
ments of Duhamel and Haller, and was led to believe that the 
formation of callus was due neither to the periosteum nor to 
the effusion of lymph, and represents the union of broken 
bones as taking place in a manner similar to cicatrization in 
the soft parts, that is to say, that the callus is formed by the 
development of granulations thrown out from the two frag- 
ments which become joined together and have then deposited 
in them the calcareous matter which gives to it the bony 
character. This opinion has in later times been adopted by 
Boyer. Macdonald believed all those who had gone before 
him in error, and regarded the callus from its commencement 
as a gelatinous mass, to which at a later period, without ever 
passing into a cartilaginous state, a deposit of calcareous 
matter gives hardness ; and brought forward, as a proof of the 
correctness of his opinion, the fact of the callus taking a 
reddish color when an animal is fed upon madder, while 
this does not take place in the cartilages. John Hunter con- 
sidered the formation of callus as due to the organization of 
the blood effused around the seat of fracture, and its con- 
sequent conversion into cartilage and bone. The ideas of 
Hunter relative to the formation of callus have in our own 
time been in great part adopted by Mr. Howship. The opinion 
arrived at by this gentleman, after the performance of a number 
of experiments, is, that the blood effused immediately after 
the occurrence of a fracture becomes the medium in which 
the ossiflc process is first established. According to him, the 
periosteum assumes by degrees the characters of cartilage, 
and the bony matter is deposited successively upon the sur- 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 15 

faces of the fractured fragments, the circumference of their 
extremities, and within the medullary cavity. Dupuytren, 
and the followers of his school, held that the process of union 
is not exactly effected in any of these ways, and their views, 
founded principally upon numerous experiments upon the 
inferior animals, have until a recent period been those gene- 
rally adopted. According to these authorities, two distinct 
epochs may be distinguished in the formation of callus, or 
rather there are two calluses successively formed. The first, 
termed the " provisional callus," is produced ordinarily in the 
space of thirty or forty days by the reunion and ossification 
of the periosteum, the cellular texture, sometimes of the 
neighboring muscles, and in the long bones, by the ossifica- 
tion of the medullary tissue. The second, called "definitive 
callus," is formed by the immediate agglutination of the two 
broken ends themselves, and is never completely finished 
before eight months or a year, by which time the provisional 
callus, that is gradually absorbed, has disappeared. 

The provisional callus surrounding the fractured frag- 
ments, though in larger quantity, is of a less solid nature 
than that which is definitively formed. The definitive callus 
when complete, though less voluminous, offers so great a 
resistance that the bone may be fractured more easily at any 
other point than that at which it was previously injured. 

These experimentalists divide consolidation after fractures 
into five periods, each characterized by distinct phenomena. 1 

The first period extends from the time of fracture to 'the 
8th or 10th day, and presents the following appearances. 
The blood poured out by the ruptured vessels of the bone, 
periosteum, medullary membrane, medulla, and the surround- 
ing cellular tissue, coagulates in all the surrounding parts, as 
well as in the medullary canal. Slight inflammation then 
follows, the cellular tissue, and the parts adjacent, becoming 
infiltrated with a gelatinous lymph. In the interior of the 
bone, the medulla and its membrane likewise become in- 

1 Sanson, Expose de la Doctrine cle Dupuytren sur le Cal., Journ. Univers. 
des Sci. Med., torn. xx. Breschet, Recherches sur la Formation du Cal., 
Paris, 1819, 4to. 



16 CONTRIBUTIONS TO PRACTICAL SURGERY. 

flamed, and pour out the same substance around and between 
the broken surfaces, and this effusion produces some thicken- 
ing about the fracture, which in consequence becomes less 
movable. The extravasated blood is in a short time alto- 
gether, or in part, absorbed : it in no case contributes to the 
reunion of the fracture, and when in large quantity, rather 
retards the .process. By the end of the period mentioned 
(10th day), the ends of the fractured bone are surrounded 
either by a viscid substance, or by a homogeneous tissue 
of a reddish color and spongy consistence, produced by the 
general engorgement and infiltration of the soft parts. 

The second period extends from the 10th day to the 20th or 
25th. During this time the swelling of the soft parts dimin- 
ishes in size, and the different tissues assume their natural 
appearances. Gradually the muscles, tendons, and other parts 
are disengaged from the general thickening by which they 
were surrounded, and there remains only a tumor, separated 
from all the neighboring parts, even from the tendons, for 
which grooves, or complete channels, are furnished, in which 
they move with more or less facility. This tumor is termed 
the "callous tumor;" it is thicker at the point of fracture 
than elsewhere, and diminishes gradually in size from this 
point to its extremities ; it is of a whitish color, and has the 
firmness and consistence of fibro-cartilage, with the fibres 
running parallel to the axis of the bone. The part of this 
tumor adherent to the bone is formed by the periosteum with 
which its substance is blended, and it is more adherent to the 
bone the nearer we approach the fracture, at which part it 
becomes difficult to separate it. Tow r ards the extremity of 
the callous tumor, the periosteum becomes again distinct and 
easily separable from the bone. The medullary canal is some- 
times obliterated at the point of injury, or even for some dis- 
tance above and below it, in consequence of its membrane 
becoming thickened ; the matter poured out within it passes 
rapidly to a state of cartilage. During this second period the 
work of restoration is principally external, the lymph by 
which the ends of the bone are glued together (within the 
callus) undergoing but little change. Even at the end of this 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 17 

period, the fracture still admits of motion, though no crepitus 
or grating can be produced. 

The third period extends from the 20th or 25th day, to the 
30th, 40th, 50th, or 60th, according to the age and state of 
general health of the patient. During this time ossification 
proceeds, and the external swelling, or provisional callus, be- 
comes entirely ossified, so as to form a firm bony clasp. The 
periosteum is thicker than in the natural state, becomes ap- 
parent upon the tumor, and is continued both above and below 
with that of the fragments. The muscles and tendons have 
by this time become free from the tumor, though they do not 
admit of much motion on account of the rigidity of the cellu- 
lar tissue. At the end of this period, in the case of a thigh, 
or leg, the fractured limb has sufficient strength to permit of 
its being used, though if the callus at this time be divided, it 
will be found that the extremities of the bones move readily 
upon each other, the substance existing between the fragments 
being as yet soft and vascular. 

The fourth period extends from the 50th or 60th day to the 
end of the 5th or 6th month. During this period the ossified 
callus becomes closer and more compact. The soft substance 
joining together the ends of the bone gradually ossifies, and 
the fractured extremities, which hitherto have not been united, 
are now found to be connected by a layer of newly formed 
and compact bone. This is termed the definitive callus, and 
in proportion to its formation is the provisional callus di- 
minished. 

The fifth period extends from the 5th or 6th, to the 8th, 
10th, or 12th month. In this period, the external provisional 
callus, having served the purpose of keeping the ends of the 
bone in contact for a certain time, is entirely absorbed, while 
that portion of it formed by the medullary effusions is also 
absorbed, and the medullary membrane returns to its natural 
state. The periosteum assumes its normal thickness and tex- 
ture, the cellular tissue its elasticity, and the muscles and 
tendons regain their free motion. Finally, the definitive callus 
is wrought into cells and canals, by which the continuity of 
the medullary cavity of the bone is restored, and the work of 
consolidation is terminated. 



18 CONTRIBUTIONS TO PRACTICAL SURGERY. 

Such are the phenomena, according to the school of Dupuy- 
tren, which accompany the formation of callus in ordinary 
cases, where the fractured fragments have been placed in a 
good position ; but sometimes it happens that the ends of the 
broken bone, instead of being placed in apposition, touch only 
at a single point, and nevertheless the bone becomes united. 
In these cases, it is asserted, the definitive callus never takes 
place, but the fragments are held together by the provisional 
deposit, which becomes permanent, and forms a firm bond of 
union. When fracture is complicated with a wound and sup- 
puration follows, after a lapse of time, ordinarily of several 
months' duration, during which splinters of bone, if there be 
any, are' thrown off, the extremities of the fragments become 
softened and covered with vascular granulations, and unite to- 
gether in a mode analogous to that of suppurating wounds of 
the soft parts, and it is this cicatrix which, by a deposit of 
bony matter in it, constitutes the callus. 

From what has been stated in regard to the formation of 
callus, it appears by this theory — 

1. That, when a fractured cylindrical bone unites, a broad 
band or support, acting like a circular splint, and termed pro- 
visional callus, is first deposited around the seat of injury, by 
which the extremities are brought together and fixed. 

2. That the permanent callus is formed between the ends 
of the bone only, and unites firmly and closely the fractured 
surfaces. 

3. That, when the permanent callus is produced, that first 
deposited, having fulfilled its transient purposes, is entirely 
absorbed. 

4. That, at the period at which splints are usually laid aside, 
and the union is looked upon as firm, the deposit of the per- 
manent callus is scarcely begun, the firmness in the broken 
part depending solely upon the temporary deposit. 

In these cases, the provisional callus forms the firm bond 
of union. By this theory phenomena may be explained which 
are sometimes observed after fractures ; the renewal of the de- 
formity after the removal of splints, at the end of a period 
that experience shows generally to be sufficient for a cure, the 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 19 

possibility of remedying, by a proper and well directed treat- 
ment, limbs that are deformed, and why this possibility exists 
only during a certain time, and then ceases, are readily ex- 
plained by it. They are fruitful too in practical hints relative 
to precautions that should be taken during the convalescence 
of fractures, particularly when oblique, as well as in regard 
to the length of time that, in certain cases, it is necessary to 
prolong the application of an apparatus, and point out the 
probability of rupturing advantageously within a certain 
period the callus of badly set bones. The more recent conti- 
nental observers, in their descriptions of the process of repair 
after fractures, although they have added much to our knowl- 
edge of the minuter histological changes in the fractured parts, 
agree in all essential points with the teachings of Dupuytren. 
Among these are Yirchow, 1 Foerster, 2 Rindfleisch, 3 Billroth, 4 
and Grurlt. 5 

Late and high authorities on this subject, however, affirm 
that the descriptions of Dupuytren and others, drawn prin- 
cipally, as they are, from the examination of fractures in the 
lower animals, cannot be applied without great deductions to 
the cases of fracture in man, and that true as the pictures are 
of the cases of the animals experimented on, they are exag- 
gerations of the process in the human subject, and that the 
doctrine of the formation of provisional callus is generally 
true only in the case of animals, in whom it depends on the 
constant movement and disturbance to which their bones 
when broken are subjected. 

From careful examinations of many specimens in the adult, 
Paget is convinced that the normal mode of repair in them 
is accomplished by intermediate callus. The principal fea- 
tures of difference between it and that just described are, (1) 
" that the reparative material is placed between the fragments, 
not around them; (2) that, when ossified, it is not a provi- 

1 Cellular Pathology, Trans, by Chance, pp. 43S-441. 1360. I 

2 Handbuch der Path. Anat, p. 865, 2d edit. 

3 Handbuch der Pathologischen Gewebelehre, p. 524, 2d edit. 1872. 

4 Chirurgische Pathologie und Therapie, p. 195. 1868. 

5 Handbuch der Lehre von den Knochenbriichen. 1862. 



20 CONTRIBUTIONS TO PRACTICAL SURGERY. 

sional, but a permanent, bond of union for them ; (3) that the 
part of it which is external to the wall of the bone is not 
exclusively, or even as if with preference, placed between the 
bone and the periosteum, but, rather, in the tissue of the peri- 
osteum, or indifferently either in it, beneath it, or external to 
it." When the fragments are placed in close apposition, he 
believes they may be joined by immediate union ; " but, if 
this do not happen, a thin layer of reparative material is de- 
posited between them ; it does not, in any direction, exceed 
the extent of the fracture ; neither does it, in more than a 
trivial degree, occupy the medullary canal; but, being inlaid 
between the fragments, and there ossifying, it restores their 
continuity." 1 

Dr. F. H. Hamilton, 2 in 1853, published conclusions nearly 
or quite identical, though independently arrived at, with those 
promulgated by Paget, and concludes that "fractures in adult 
human bones, whether placed end to end or overlapped, unite 
most naturally and most promptly, either immediately or 
mediately, and in the same manner that soft tissues unite; 
that is to say, without the interposition of any reparative 
material, or through the medium of an intermediate, per- 
manent callus, and that all deviations from these simple 
methods are accidental, or the result of disturbing influences." 3 

Perfect osseous union, however, is sometimes not effected 
between the extremities of a fractured bone, and we propose 
now to investigate the appearances presented by the parts 
where this failure exists. Authorities differ as to the state in 
which the bones are found upon dissection in ununited frac- 
tures, though generally, the opinion maintained by Boyer, that 
a true joint, with a well-marked capsular ligament contain- 
ing a fluid resembling synovia, is never formed, has been 
adopted. That in the majority of instances this opinion may 
be correct, we are willing to acknowledge, though an exami- 
nation of such post-mortem examples as we have found re- 
corded, as well as instances that we have ourselves observed, 

1 Lects. on Surgical Pathology. Lond. 1863. 

2 New views of Provisional Callus. Buffalo. 

3 On Fractures. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 21 

show that it is not uniformly the case. The mode of union 
between the fractured extremities in these cases mav be 
described as of four kinds. 

In the first, the bones are united together by the fibro-car- 
tilaginous mass, which has been described under the name of 
the callous tumor, the formation of which has gone on regu- 
larly, but in consequence of some retardation in the process, 
bony matter is not deposited, and as a consequence, it wants 
solidity, the part continuing easily movable. It is in this 
state that the bones are found in what are termed delayed con- 
solidations, and it is to this class of cases, as we shall here- 
after see, that the treatment by rest and compression is pecu- 
liarly suited. The rough handling of a limb in this state is 
always accompanied with some pain, a circumstance of much 
importance in its diagnosis. 

In the second class of cases, there is entire w T ant of union of 
any sort between the fragments, the ends of which seem to be 
diminished in size, and are extremely movable beneath the in- 
teguments. The limb in these cases is found greatly shrunken, 
and hangs perfectly useless. 

In the third and most common class of cases, the medullary 
canal is obliterated in both fragments, and the ends of the 
bone are found more or less absorbed and rounded, or are 
pointed and covered by a tissue resembling the periosteum, 
and are connected together by strong ligamentous or rlbro- 
ligamentous bands, passing from the extremity of one frac- 
tured fragment to that of the other. Sometimes this bond of 
union is constituted by a single ligament, while in other in- 
stances it is made up of several narrow bands having separate 
attachments: in either case the newly formed substance is 
firmly adherent to the bones, and if of any length is in a 
high degree pliable. Instances of this sort of union are often 
seen after transverse fractures of the patella and olecranon. 

In the fourth class of cases, a dense capsule without open- 
ing of any sort, containing a fluid similar to synovia, and 
resembling closely the complete capsular ligaments, is found. 
In these cases, the points of the bony fragments correspond- 
ing to each other are rounded, smooth, and polished, in some 



22 CONTRIBUTIONS TO PRACTICAL SURGERY. 

instances are eburnated, and in others are covered with points, 
or even thin plates of cartilage, and a membrane closely 
resembling the synovial of the natural articulations. It is in 
this kind of cases that the member affected may still be of 
some utility to the patient, the fragments being so firmly held 
together as to be displaced only upon the application of con- 
siderable force. Boyer, 1 Hewson, 2 Chelius, 3 and other writers 
have doubted the existence of these newly formed joints ; but 
the observations of Sylvestre, 4 of Brodie, 5 of Beclard, 6 Home, 7 
Howship, 8 Otto, 9 Kuhnholtz, 10 Houston, 11 Key, 12 Cruveilhier, 13 
and Langenbeck, all show that such are occasionally found. In 
a number of experiments on resection of the hip-joint in animals, 
made by Chaussier, 14 Koehler, and Wachter, 15 the muscles were 
found to have drawn the parts together, the extremities of the 
femur and the corresponding portions of the ischium being in- 
crusted with a cartilaginous substance and membranous cap- 
sule, containing serous fluid formed around the new articula- 
tion. In nine false articulations which he produced in a series 
of experiments upon dogs, M. Breschet 16 observed six in which 
the extremities of the bone were rounded, and cartilages, syno- 
vial membranes, and all the other appearances constituting a 
true joint formed, while in three only were the bones connected 
by means of a ligamentous matter passing from one extremity 
to the other. 

When the fractured fragments have been for a long time 

1 Maladies Chirurgicales, iii. p. 103. Paris, 1831. 

2 North American Med. and Surg. Journ., No. 9, p. 7, 1828. 

3 Traite de Chirurgie, Trad, par Pigne, p. 150. Bruxelles, 1836. 

4 Nouvelles de la Republique des Lettres of Bayle, p. 718, July, 1685. 

5 Loud. Med. Gaz., xiii. p. 57, 1833. 

6 General Anatomy, Trans, by Hayward, pp. 149, 248. 

7 Trans, of Med. Chir. Soc. of Edinburgh, i. p. 233, 1793. 
* Med. Chir. Trans., viii. p. 517, 1817. 

9 Patholog. Anat., Trans, by South, i. p. 138. 

10 Journ. Complementaire, iii. p. 291. 

11 Dublin Med. Journ., viii. p. 493. 

12 Cooper on Fractures and Dislocations, 4th ed. p. 508. London, 1824. 

13 Anat. Patholog., torn. i. 374. 

14 Mems. Med. Soc. d'Emulation, torn. iii. 

15 De Articulis Extirpandis. Groningen, 1810. 16 Loc. cit. p. 34. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 23 

disunited, the structures of the bones themselves undergo a 
change, and become very light, being deprived of their reticu- 
lated spongy substance, and reduced to a mere shell of com- 
pact structure. 

The causes of non-union after fracture are either constitu- 
tional or local. Among the constitutional causes, the exist- 
ence of syphilis in the system is generally looked upon as 
being sufficient to retard, or altogether prevent, the process 
of union after fractures. Numerous instances in which this 
has been the apparent cause might be cited from the old 
writers. Among the moderns, M. Sanson is one of those 
who lay most stress upon it. "I have twice," says he, "had 
occasion to observe the marked influence of syphilis in re- 
tarding consolidation. One of the cases was a fracture of the 
leg, which was not firm after eight months' employment of 
the ordinary means of treatment. The other was a fracture 
of the humerus, which was not united after eighteen months, 
except by a soft and flexible substance. In both these cases, 
unequivocal proofs existed of concomitant syphilitic affec- 
tions, and, after an anti-syphilitic treatment of two months 
was employed, consolidation took place." 1 Berard 2 mentions 
the case of a simple fracture of the leg, observed by M. 
ISTicod, in which there was no union after nine months of 
treatment, when, syphilitic symptoms being discovered, the 
patient was placed under a mercurial course, and consolida- 
tion took place. An instance was related to the Academy of 
Medicine of Paris, by M. Beulac, 3 of a fracture that had ex- 
isted two months, where the consolidation was retarded by 
syphilis, under which the patient labored, and at the same 
sitting several members stated like facts. The following 
case, in which want of union seemed owing to the existence 
of syphilis, has been obligingly communicated to me by Dr. 
Condie: On the 28th of August, 1828, J. Kowen, set. 48, 
fractured both bones of the left forearm, some inches above 

1 Diet, de Med. and Chir. Prat. iii. p. 492. 

2 Des causes qui empechent ou retardent la consolidation des Fractures 
et des moyens de l'obtenir. — These, Paris, 1833. 

3 Journ. de Med. Chir. and Pharm. in 40 vols., torn. xxv. p. 216. 



24 CONTRIBUTIONS TO PRACTICAL SURGERY. 

the wrist, by a fall from a hay loft. A few hours subsequent 
to the accident the bones were properly reduced, and the arm 
put in splints. He was a man of dissipated habits, and had 
been, since his twenty -first year, repeatedly under treatment 
in hospitals for syphilis. At the time of his accident, he was 
laboring under ulceration of the throat, nodes and cutaneous 
blotches, and his gums and breath exhibited indications of 
mercurial action. The Lisbon diet drink and a nourishing 
diet were ordered, in addition to exercise in the open air. On 
the 30th of September, no attempt at union having taken 
place, Dr. Physick saw the patient, but suggested no change 
in the treatment. On the 22d of November, eighty-five days 
after the occurrence of the accident, when the patient was 
last seen, no union was perceptible. Breschet 1 mentions the 
case of an adult, in whom several fractures existed, all. .pro- 
duced by muscular action alone, and who voided daily with 
his urine a large quantity of sandy matter. Syphilis being 
suspected as the cause of this state, the rob of LafTecteur was 
administered, sometime after which consolidation of the 
broken bones occurred. Opposed to these statements, how- 
ever, the great experience of M. Lagneau 2 may be quoted, 
who mentions that he has witnessed numerous examples of 
fracture, in which union took place promptly, notwithstanding 
the existence of constitutional syphilis. Oppenheim, 3 too, 
avers, that he has observed various cases, in which, general 
syphilis being present, fractures united exceedingly well, and 
is inclined totally to discard the suspicion that syphilis, in 
any way, retards the union of broken bones. I have, myself, 
treated fractures in patients laboring under constitutional 
syphilis, and have never noticed any delay in the union. M. 
Berard, after numerous researches, sums up his opinion in the 
following language: 4 "Despite the numerous occasions in 
which surgeons have witnessed the coexistence of syphilis 
with fractures, it has been very rarely proved that the syphi- 

1 Diet, de Med. Art. Pseudarthrose, 2d edit. p. 231. 

2 Expose des Symp. de la Mai. Venerienne, p. 525. Paris, 1818. 

3 On False Joints, in Zeitschrift fur die Gesammte Medicin, No. 5, May 
1837. 

4 Op. citat. p. 11. 



OCCURRENCE ON NON-UNION AFTER FRACTURES. 25 

litic virus exercises any influence upon the formation of 
callus." 

Pregnancy and lactation are stated in most of our treatises, 
also at times to retard, or prevent, firm union from taking 
place after fracture. 

As a general rule, it may be said that these states do not 
interfere with the occurrence of bony union. Of fifty-six 
cases examined by Mr. Amesbury, 1 but two happened during 
the process of gestation, and these he is not disposed to 
attribute to the peculiar disturbance of the system which is 
observed in pregnancy. Callisen 2 reports that he has, in 
several cases, seen fractures in pregnant women get perfectly 
well, though the time required for firm union was a little 
longer than that ordinarily demanded. Of four cases of 
fracture which came under the care of Mr. Latta, in the fifth, 
sixth, and seventh months of pregnancy (two of the thigh, 
one of the tibia, and one of the forearm), all were cured in 
the ordinary time. 3 Mr. Listen 4 has often seen fractures iu 
women carrying children unite as speedily and firmly as if 
the patients had not been in that state, and otherwise in 
robust health ; but observes, " profuse uterine or vaginal 
discharges, or determination to particular parts or organs, 
will certainly retard union." Leveille mentions the case of 
a pregnant woman cured of a simple fracture in the usual 
time. 5 Breschet 6 has observed numerous cases at the Hotel 
Dieu of Paris, in which fractures have occurred in pregnant 
women, and has never observed the slightest influence exerted 
upon the reparative process by this state of system. Several 
of my friends, who have had opportunities of observing frac- 
tures in this class of patients, have assured me that the in- 
juries have been repaired in the usual period. That, however, 
these states do occasionally retard the reparation of fractured 

1 On Fractures, 2d ed. p. 197, 1829. 

2 Syst. Chir. Hodiern. Pars 1, § 1313. 

3 System of Surgery, iii. p. 363. 

4 Elements of Surgery, 2d ed. 1839, p. 686. 

5 Nouvelle Doctrine Cnirurgicale, torn. ii. p 159. 

6 Diet, de Med., torn, xxvi., 2d. ed., p. 231. 



■J 



26 CONTRIBUTIONS TO PRACTICAL SURGERY. 

bones, there can be no doubt. Heister 1 observes, " when 
fractures happen to big-bellied women they are seldom cured 
till they have got rid of their burthen." Werner 2 has pub- 
lished the case of a fractured radius in a pregnant woman, 
where the cure was apparently retarded for a long time by 
this circumstance, and though the union took place previously 
to delivery, the callus was not very firm till after that event. 
Fabricius Hildanus, 3 Wilson, 4 Ferdinand Hertodius, 5 have all 
witnessed cases in which this retardation had taken place. A 
remarkable and well-detailed instance of this kind is recorded 
by Mr. Alanson. 6 It is that of a delicate female, who, in the 
second month of pregnancy, met with an oblique fracture of 
the tibia, which, in spite of a well-directed treatment, had not 
united when she was delivered at full time (seven months 
after the accident), but which, as she recovered strength after 
her confinement, began to unite, and nine weeks after this 
period was able to walk about her room with a firm limb. 
What proves beyond a doubt in this case that the want of 
union was owing entirely to her pregnant state was, that three 
months before impregnation she had been very happily and 
speedily cured of a fractured femur. 

Another well-described case, in which a fracture received 
during pregnancy did not unite till after delivery, was ob- 
served by Dr. Bard of New York, and is to be found in the 
Philosophical Transactions, xlvi. p. 397, 1750. In this in- 
stance the left forearm was fractured obliquely in the third 
month of pregnancy ; finding the arm continued flexible at 
the end of seventy-five days, though the ends of the bones 
were in perfect apposition, Dr. B. applied an apparatus to keep 
the limb in a good position, and gave encouraging hopes to 
the patient that after her labor, the economy of nature would 
be more immediately directed to the recovery of the use of 

i System of Surg., Lond. 1763, p. 120. 

2 Kichter, quoted from Cooper's Diet., p. 546, ed. 1838. 

s Opera. 1681, Cent, 5, Obs. 87, and Cent. 6, Obs. 68. 

4 On the Human Skeleton, p. 214. 

5 Ephem. des Cur. de la Nat. Ire annee obs. 25, quoted from Bib. Choisie 
de Med. xxiv. p. 595. 

6 Med. Obs. and Inquiries, iv. 1772. 



OCCURRENCE OP NON-UNION AFTER FRACTURES. 27 

her arm. In less than a month after her delivery, the callus 
was fully formed, and the patient recovered the use of her 
arm. M. Lepiez 1 has given an interesting case of the same 
kind. The patient, two and a half months advanced in preg- 
nancy, fractured her humerus, besides receiving some severe 
wounds of the soft parts. At the end of six weeks the wounds 
were healed, but the fracture had not united. The treatment 
was continued in the hope of this occurring after her confine- 
ment, and took place firmly and well at the expiration of a 
month after that event. Another observation of fracture of 
the middle of the femur, occurring in a young and healthy 
woman, advanced to the third month of pregnancy, treated at 
the Hospital St. Antoine in Paris, in whom union failed to 
take place until one month after delivery, when the consolida- 
tion became perfect, has been detailed by Dupuy. 2 The fol- 
lowing case, kindly furnished to me by Dr. Condie of this city, 
also strikingly shows the influence that may be exerted by a 
state of pregnancy upon the consolidation of fractures. S. R., 
set. 36, on the 13th of October, 1820, being then in the eighth 
month of her third pregnancy, fell in going up stairs and frac- 
tured her right humerus immediately below the insertion of 
the deltoid muscle. The fractured bone was carefully ad- 
justed within half an hour after the accident, and, the patient 
being to all appearance in perfect health, a speedy union was 
anticipated. No union occurring, Dr. Physick saw the patient 
on the 13th of November, and carefully examined her arm. 
He remarked, that, according to his experience, fractures oc- 
curring in pregnant females often remained ununited until 
after parturition, when union very generally and rapidly took 
place, and believed this would be the case with S. R. provided 
motion at the seat of injury was guarded against. 

On the 27th of November, the patient was delivered of a 
healthy child, rather above the common size, and by the 31st 
of December the bone had become firmly united. 

Whether the states of pregnancy or of suckling have any 
direct effect in preventing union of the bones, or whether this 

1 Journ. de Chirurg., 1845. 2 Gaz. Medicale, 1855, p. 408. 



28 CONTRIBUTIONS TO PRACTICAL SURGERY. 

is only in consequence of the debility which these conditions 
of system often induce, is undetermined. I am myself inclined 
to adopt the latter supposition, and in support of it will ad- 
duce the cases reported by Sir Stephen Love Hammick. "I 
have seen," observes this author, 1 "three cases of this sort, 
one of the leg, in a woman in the first months, who was ex- 
tremely debilitated from an incessant irritability of stomach, 
causing her to reject all her food, but as the pregnancy ad- 
vanced her stomach became tranquil, when on recovering her 
strength the bone united. Another had a fracture of the 
humerus in the latter months ; the patient was in a state of 
great exhaustion;' after her delivery she would persist in 
nursing the child, which continued her weakness, and it was 
not till two months after she consented to wean it that the 
bone united by the vigor of the system having returned. The 
third was in the last months of pregnancy, and after delivery, 
not attempting to nurse the infant, she rapidly improved in 
health, and the limb quickly got well." 

Cancer has been placed among the causes which hinder the 
consolidation of fractured bones, though perhaps by the gen- 
erality of authors it is denied to exert any influence over the 
process. " Women laboring under cancer," says Sir B. 
Brodie, 2 " are liable to a similar disease of different bones of 
the body, which then become brittle and very liable to break. 
I saw an old woman dying of this disease who in turning in 
bed broke the femur ; union took place here as well as under 
ordinary circumstances. I attended a lady who had cancer of 
the breast, and a scirrhous affection of the collar bone, and one 
day in moving her arm, the collar bone was broken, but it 
united just as if it had been a healthy bone." Mr. Liston 3 
has recorded the case of a female, set. 49, affected with carcino- 
matous tumors under the jaw and in both breasts, as well as 
in the uterus and other internal organs, in whom firm union 
occurred after two fractures of the left and one of the right 
humerus, all received within fourteen months, and produced 

1 Practical Remarks on Amputation, Fractures, etc., p. 121. 

2 Lond. Med. Gaz., xiii. p. 56, 1833. 

3 Practical Surgery, 2d American edition, p. 100. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 29 

by very slight causes. Mr. Coates and Sir Charles Bell 1 have 
given, each a case, of fracture occurring in cancerous patients, 
where no sort of union had formed after eight and six weeks, 
and where cancerous matter was found deposited in the bones. 
M. Coling 2 describes the case of a woman, aged sixty-eight, 
affected with an encephaloid tumor of the neck, who fractured 
the femur in the act of stooping to urinate, in whom no union 
took place, and on dissection, fourteen months after the acci- 
dent, the same encephaloid matter was found to be developed 
to a great extent around the fractured bones. I have seen two 
instances of fracture of the femur in middle-aged persons, 
produced by slight causes, in which like deposits were found. 
After a very careful examination of what has been written 
upon the subject, I believe it may be stated that, where the 
fracture arises in consequence of a true cancerous deposit 
around, or in the interior of the bones, and producing absorp- 
tion of their tissue, no union takes place, but where, as is 
usually the case, it is owing to a mere brittleness of the bones 
occasioned by what has been denominated by Mr. Curling 
eccentric atrophy, fractures, though occurring from very slight 
causes, will unite readily. 

Fragility of the Bones. — The same cause which gives rise to 
undue fragility in the bony structure might, a priori, be sup- 
posed to retard, if it did not altogether prevent, their consoli- 
dation after fractures. Experience however proves this not 
to be the case, and generally, indeed, it may be said, that, 
where a proneness to fracture from trifling causes exists, these 
accidents are repaired with great facility. Dr. Good 3 mentions 
the instance of a lady get. 72, who broke both femurs by 
merely kneeling down at church, and who had the humerus 
also broken in the efforts made to remove her, without any 
violence, and with little pain. Scarcely any constitutional 
disturbance followed, and the bones united in a few weeks. 
Mr. Tyrrel 4 had under care a patient who had suffered twenty- 
two fractures, and the accidents were repaired with greater 

1 Lond. Med. Gaz., xiii. 2 Archiv. Gen., vol. xxxvii. p. 527, 1835. 

3 Study of Medicine, v. p. 332, 3d ed. 

4 St. Thomas's Hosp. Reports, vol. i. 



30 CONTRIBUTIONS TO PRACTICAL SURGERY. 

facility than in other individuals, the femur being perfectly 
firm at the end of three or four weeks. An interesting 
history has been furnished by Dr. Pauli of Landau 1 of an 
hereditary brittleness of the bones occurring in a healthy 
family, and one apparently free from any scrofulous or other 
taint. Three of them had each had two fractures, another 
three, either of the arm or leg ; one of them had as many as 
five fractures of one or the other extremity, all produced with- 
out any considerable violence. In every instance the fracture 
was speedily cured, generally the callus being perfectly firm 
at the end of three weeks, and, when the same bone was broken 
a second time, it never occurred at the seat of callus. Pro- 
fessor Gibson 2 speaks of the case of a young man who in a 
period of twenty-three years experienced twenty-four fractures. 
From infancy he had been subject to fractures from the slight- 
est causes, and his limbs had all been repeatedly broken, even 
from so trivial an accident as catching the foot in a fold of 
carpet whilst walking across the room. The clavicles had 
been fractured eight times. The boy always enjoyed excellent 
health, and the bones united without difficulty or much de- 
formity. The same author furnishes four other cases, observed 
by different gentlemen in our country, in all of which fragility 
existed in remarkable degrees. In the cabinet of M. Esquirol 3 
the skeleton of a rachitic woman is to be seen, in which exist 
traces of upwards of two hundred fractures, all more or less 
firmly consolidated. 

Scurvy ', fevers of a low type, or any other disease inducing 
great debility or actual prostration, may also prevent the re- 
parative process after fractures from taking place as in ordi- 
nary cases. 

The cause of want of union is sometimes to be found in the 
general impoverished and lad state of the system, produced by 
improper abstinence from food, or the withdrawal of an 
habitual stimulus. The following cases illustrative of this 



1 Journ. de Cliirurg., Jan. 1845. 

2 Institutes and Practice of Surgery, i. p. 233, 1838. 

3 Dictionnaire de Medecine, xiii. p. 407, 2d ed. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 31 

cause are given by Sir B. Brodie. 1 u A gentleman was grow- 
ing fat, and, not liking to do so, he placed himself on a very 
slim diet, though accustomed to good living previously. After 
six months of starvation he broke his arm, and the bone 
would not unite. I saw him many months afterwards, and 
there was scarcely any union, even by soft substance. An- 
other patient about whom I was consulted, a lady, was grow- 
ing fat, and thought she would also prevent it by pursuing a 
similar system of diet. Some months afterwards she broke 
her arm, and union did not take place." A striking instance 
of the same cause in preventing union is related by M. Noel, 2 
of a girl, aetat. 18, of good constitution, in whom no attempt 
at union had taken place after a fracture of the leg at its 
middle part, at the end of eight months. The patient was 
greatly reduced from want of nourishment, she having sub- 
sisted for some time upon six ounces of bread, with water, 
per diem. Supposing want of union to depend upon insuffi- 
cient nourishment, she was placed upon a good diet, and about 
six weeks afterwards union of the fractured bones was perfect. 
Beckett relates the case of a patient, aetat. 23, with fractured 
os humeri, in whom the loss of a large quantity of blood, and 
the denying him a competent sustenance, prevented reunion 
till the end of nine months. 3 Mr. Wilson 4 mentions an in- 
stance in a woman with a fractured leg, who had led an in- 
temperate life, but who after her accident had been refused 
strong liquors, where union did not occur, but, upon a mode- 
rate quantity of spirits being allowed her, it got well almost 
immediately. On the breaking of her other leg, which hap- 
pened within a year after her first accident, spirits were not 
entirely refused her, and the bones united in the usual time. 
A very curious case has been recorded by Mr. Fowler, of 
Cheltenham, 5 showing that, while a patient was suffering from 
haemoptysis, nature furnished the cartilaginous cement very 
abundantly; and that, when this symptom ceased, the earthy 

1 Lond. Med. Gaz., xiii. p. 56, 1833. 

2 Prix de TAcad. de Cnirurg., v. p. 45, 8vo., Paris, 1819. 

3 Chirurgical Observations, p. 16. 

4 On the Human Skeleton, 1820, p. 227. 

5 Med.-Chirurg. Rev., vol. vii. p. 574, 1ST. S., 1827. 



32 CONTRIBUTIONS TO PRACTICAL SURGERY. 

matter was liberally supplied, and a large portion of the car- 
tilaginous medium removed. The subject was a male, aged 
fifty, of a consumptive tendency, who fractured his femur. 
For the first three weeks he appeared to do well, and then be- 
gan to complain of pain in the chest, and had bloody expec- 
toration. About the seventh week callus was found to have 
been profusely deposited around the seat of fracture, being 
"a mass nearly equal in size to the head of a new-born infant," 
but so entirely deficient in earthy material, that the weight of 
the leg was sufficient to bow the thigh at the fractured part. 
The bone was again adjusted as before, the expectoration 
suddenly ceased, the appetite, appearance, and strength rapidly 
improved, and at the end of the twelfth week the callus had 
diminished to nearly half its size, and the patient could bear 
his weight upon it. A case in which want of union may per- 
haps be attributed to slim diet together with repeated bleed- 
ings, is given by Dr. Hewson. 1 This patient was admitted 
into the Pennsylvania Hospital in March, 1827, on account of 
an imperfect union of the tibia near its centre. In August, 
1818, both bones of the leg were broken. He was subjected 
to a severe antiphlogistic treatment, and lost several pounds 
of blood. It was not until six weeks after the accident that 
he was allowed any portion of animal food. Other striking- 
illustrations of the effect of an altered mode of living may 
be found in the Medico- Ohirurgical Review for January, 1836. 

The influence of a low diet, long continued, upon the parts 
interested in compound fractures, must have been noticed by 
all surgeons, and the good effect produced in such cases by an 
increased diet, and the allowance of an accustomed stimulus, 
as well in causing the more rapid deposit of callus, as in im- 
proving the state of the wound, have been observed. That 
the large abstraction of blood alone will not prevent the for- 
mation of callus is well seen in the following cases. 

Isaac Yorke, aetat. 19, was admitted into the Pennsylvania 
Hospital October 5th, 1801, for fracture of the right thigh. 
His accident had happened one week previously to his admis- 

1 North American Journ. for Jan. 1828, p. 11. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 33 

sion, during which time he had been deliriou-s, and had under- 
gone five bleedings, in all amounting to one hundred and two 
ounces. He continued to do well until the 7th, when his de- 
lirium returned, and between this date and the 15th he was 
bled at different times to the amount of ninety ounces, making 
in all one hundred and ninety-two ounces ; from the 15th he 
recovered rapidly, and was discharged from the hospital Jan- 
uary 13th, 1802. 

Jas. Orr, setat. 32, was admitted May 16th, 1804, for com- 
pound fracture of the leg two inches above the ankle, and 
injury of his thorax. Great pain and difficulty of breathing 
followed the accident, to relieve which he lost thirty ounces 
of blood in the first twenty-four hours following it. On the 
20th delirium set in, and in the two following days sixty-two 
ounces more of blood were taken from him, making in all 
ninety ounces ; after this his symptoms abated, and he re- 
covered rapidly. 1 

The influence of the nervous system over the processes of 
reparation in the body is well known, and that want of nervous 
influence might alone be sufficient to prevent consolidation 
after fracture from occurring, has been supposed. That it 
may be a sufficient cause there can be no doubt; an instance is 
mentioned by Mr. Travers, 2 in which union failed to proceed 
after a fracture of the leg that was paralyzed from fracture of 
the lumbar vertebras, although the humerus, broken at the 
same time, united perfectly in the usual period. Mr. Benjamin 
Phillips 3 has seen a case in which the same injury that frac- 
tured a man's leg injured the lower part of the spine; he lived 
five weeks, but there had been no effort at reparation. Dimin- 
ished nervous influence will not, however, in all instances, 
hinder the formation of callus, as is shown by a case recorded 
by Mr. Busk, 4 of a gentleman, astat. §b, who had been more 
or less paralytic for upwards of twenty years, for the last 
twelve or fourteen of which he had been completely deprived 

1 Penn. Hosp. Case Book, i. pp. 27, 31. 

2 Further Inquiry, etc., p. 436. 

3 Lond. Med. Gaz. for May, 1840, p. 327. 

4 Lond. Med. Gaz. for April, 1840, p. 97. 



34 CONTRIBUTIONS TO PRACTICAL SURGERY. 

of all power of motion and sensation from the loins down- 
wards, who fractured his left leg below the middle; and in 
whom at the end of five weeks the bones had firmly united. 

Another instance of the same kind has been reported by M. 
Reynaud 1 in which the formation of callus and firm consolida- 
tion took place in the usual time, and Mr. Toogood 2 attended 
a man who had for many years been in a weak, nervous, and 
half-paralytic state, who broke his femur by turning in bed, 
which was treated in the common way and united after a con- 
siderable time. Roechling has proved by experiments upon 
young dogs, that the formation of callus, though not entirely 
prevented by division of the nerves of an extremity, was 
nevertheless greatly retarded, and indeed did not take place 
perfectly. 3 The last experimenter whose statement I have 
seen on this matter 4 asserts, that where the sciatic nerve was 
resected in lambs consolidation of a fracture took place as 
perfectly and rapidly as where the nerve was untouched. 

Three interesting cases of fracture have been reported to 
the Societe de Chirurgie by Baron Larrey, to prove the facility 
of the production of fractures in paralyzed limbs. In one of 
the cases there was incomplete paraplegia of the lower limbs, 
with increased sensibility. During a moment of suffering, the 
patient had to put one of his legs upon the other, while he 
pressed upon the thigh with his hands, and the femur broke 
at about its middle. The fracture was very long in being 
cured, and the patient died from the progress of his paralysis. 
In a second case, there was also paraplegia besides amaurosis. 
In making an effort to put on a boot, the patient, aged thirty, 
broke the femur in its lower part. The fracture was com- 
pound and the upper fragment protruded. The spasmodic 
movements prevented the contact of the fragments, but never- 
theless, irregular consolidation took place. The patient died. 
In the third case, there was incomplete paraplegia in an officer, 
aged forty. The fracture was oblique, and caused by an effort 

1 Journ. de Chirurg., p. 349, 1843-4. 

2 Provin. Med. Journ., vol. ix. 1842. 

3 Quoted from Miesclier, "De Inflamniatione Ossium. Berolini," 1836. 
* Oilier, vol. i. p. 230. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 35 

to take off his boot, and was at the inferior part of the bone. 
More than ten months have elapsed, and consolidation has not 
yet taken place. 1 

Gutting off the direct supply of blood to an extremity by liga- 
ture of the principal arterial trunk might, a priori, be supposed 
sufficient to retard union after fracture. This however does 
not seem always to exert a marked influence upon the process. 
Petit 2 mentions a fractured leg accompanied by rupture of the 
anterior tibial artery, in which union was effected in the usual 
way. In the Surgical Essays of Mr. B. Cooper, is a case of 
fractured femur accompanied with injury to the popliteal artery, 
where, although the femoral was taken up, the fracture was 
soundly united in six weeks. In a case, however, of a similar 
kind, reported by Dupuytren, 3 the work of consolidation went 
on slowly, the nutrition being weakened in the limb by the 
ligature of the artery. At the end of the first month, the callus 
had scarcely begun to be formed ; at the termination of the 
second, union was very weak, and it did not become perfectly 
solid till after the expiration of four months. In animals, 
such as guinea pigs, rabbits, etc., Brodie has found by expe- 
riment, that the reparative process in a fracture of the thigh 
bone is delayed in its commencement for a week or a fortnight, 
by placing a ligature on the femoral artery, but at the end of 
that time union goes on as though no such operation had been 
done. 4 

Berard 5 has shown that the period at which the epiphyses 
are joined to the diaphyses of the long bones, depends upon 
the direction of the nutritive artery — for example, it is found 
that in the humerus, where the direction of this vessel is from 
above downwards, consolidation takes place soonest at its 
inferior extremity. In the forearm, the course of the nutrient 
vessel is from below upwards, and here consolidation of the 
epiphyses is found to occur at the elbow sooner than at the 
wrist. In the inferior members, on the contrary, the epiphyses 

1 Med. Times and Gaz., vol. xvi. N. B., 1858, p. 44. 

2 Mai. des Os, quoted from the thesis of Berard, p. 27. 

3 Lecons Orales, iv. 618. 4 Lancet, i. p. 381, 1840-1. 
5 Archives Generates, xxxvii. p. 176, 1835. 



36 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



composing the knee are the last which become firm, because 
in the femur the nutritious artery runs upwards, and in the 
bones of the leg it courses from above downwards. Aware 
of these facts, M. Gueretin 1 was led to examine into the in- 
fluence which the direction of the nutritious arteries exerted 
upon the consolidation of fractures, and has asserted that un- 
united fractures are most common in the points opposite to 
the direction of the nutritive vessel. The following analysis 
of 35 cases, to show the relation between the seat of ununited 
fractures and the nutritious vessels, copied from his paper, 
possesses much interest: — 



Bones 
affected. 



No. of 
Cases. 



Humerus 9 

Do. 4 

Forearm 1 

Do. 7 

Femur 3 

Do. 5 

Leg. 4 

Do. 2 



Seat of Fracture. 

Above the entrance of the nutrient artery (upper half of 

bone). 
Below the entrance of the nutrient artery (lower half of 

bone). 
Above the entrance of the nutrient vessels of the two bones 

(superior third). 
Below the entrance of the nutrient vessels of the two bones 

(lower half). 
Above the entrance of the nutrient vessel (superior half). 
Below the entrance of the nutrient vessel (lower half). 
Above the entrance of the nutrient vessels of the two bones 

(superior third). 
Below the entrance of the nutrient vessels of the two bones 

(lower half). 

As the seat of the entrance of the vessel varies, though but 
little, and very rarely, cases of non-consolidation have been 
taken for this table which are distant at least one inch from 
the point usually assigned for its entrance. 

In addition to the researches of M. Grueretin, it has been 
shown by Mr. Curling, 2 that, in fractures of the long bones, 
the portion below the entrance of the nutrient artery becomes 
gradually atrophied, being supplied only by the periosteal 
branches. Thus, in femurs fractured below the entrance of 
this vessel, the inferior cavity of the lower extremity becomes 
enlarged, the cancelli expanded, and the walls thinned. A 
like alteration is observed in fractured tibia, whilst in a hu- 
merus, broken near the middle and somewhat above the 



1 Presse Medicale, i. p. 45. 



2 Med.- Chir. Trans., xx. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 



37 



entrance of the nutrient artery, the upper portion was the seat 
of change. My own researches on this point do not, however, 
confirm those of M. Gueretin. An analysis of 41 cases in 
which I find the exact point of fracture indicated, gives the 
following result : — 



Bones 

affected. 

Humerus 



No. of 

Cases. 



Do. 



Forearm 



Femur 


7 


Do. 


6 


Leg. 


1 



Seat of Fracture. 

4 Above the entrance of the nutrient artery (upper half of 

bone). 
9 Below the entrance of the nutrient artery (lower half of 

bone). 
1 Above the entrance of the nutrient vessels of the two bones 
(superior third). 
Do. 3 Below the entrance of the nutrient vessels of the two bones 

(lower half). 
Above the entrance of the nutrient vessel (upper half). 
Below the entrance of the nutrient vessel (lower half). 
Above the entrance of the nutrient vessels of the two bones 
(superior third). 
Do. - 10 Below the entrance of the nutrient vessels of the two bones 
(lower half). 

Advanced age is placed among the causes which always retard 
the consolidation of fractured bones, though the reading of 
observations reported, and daily experience, do not confirm 
it. In some ca'ses of this kind, I have seen the callus deposited 
and firm union occur remarkably soon. In 1838, two instances 
in which this took place were treated by me at the Pennsyl- 
vania Hospital. In one of them, occurring in a man aged 
ninety, the humerus was fractured near its middle, and under 
the usual treatment, firm union took place at the end of six 
weeks. In the other, a decrepid female, aged eighty, who died 
from exhaustion eighty-four days after fractures of the middle 
of the femur, and the ilium, the mass of matter thrown out 
around the fractured portions was truly astonishing. An in- 
stance is mentioned by Professor Horner, 1 in which a simple 
fracture of the os humeri occurring in a female, aged ninety, 
was firmly united at the end of five weeks. Firm union of 
an oblique fracture of the femur near its middle, on the forty- 
fourth day, in a woman eighty-nine years of age, is recorded 
by Dr. Henderson, 2 and the same result in six weeks in the 



Treatise on Anatomy, i. p. 27. 2 Lond. Med. Gaz., Jan. 1843. 



88 CONTRIBUTIONS TO PRACTICAL SURGERY. 

arm of a woman, in her eighty-seventh year, is noted by 
Paul. 1 Adverting to the supposed influence of old age in 
causing imperfection or failure of bony union, Dr. Wright 
thus gives his experience : " I have been frequently struck 
with the resources of the system in old age, as displayed in 
the prompt and perfect repair of injuries both of the soft and 
solid parts of the body. In the closing of wounds, the filling 
up and healing of extensive ulcers, and the firm reunion of 
fractures, it has occurred to me to observe all those processes 
accomplished with a facility and completeness scarcely ex- 
ceeded at any age, in some instances where the subjects of such 
accidents had passed the eightieth year of life." 2 Bonn, 3 how- 
ever, has furnished two observations, where advanced age 
appeared to be the only circumstance which retarded the for- 
mation of callus. Some idea of the influence of age in the 
production of false joint may be derived from an analysis of 
112 cases extracted from our table, in which the age is noted. 

Of the age of 20 and under there were ... 14 
Between the ages of 20 and 30 there were . . 53 
Between the ages of 30 and 40 " " . . .21 
Above the age of 40 " " . 24 



112 

According to Larrey, 4 even the season and atmospheric 
temperature may exert some influence upon the consolidation 
of fractured bones ; he relates that the gunshot wounds of the 
superior extremities complicated with fracture, especially 
those of the humerus, received by the French soldiers in 
Syria, although dressed according to art, were almost all fol- 
lowed by accidental articulation, which he attributes to the 
following causes: — 

1st. To the continual motion to which the wounded were 
exposed after their departure from Syria, until their arrival 
in Egypt, and being obliged to travel mounted or on foot. 

1 Lond. and Edin. Month. Journ., vol. i., 1841. 

2 Amer. Journ. of Med. Sci., iv. p. 273. 

3 Descript. thesauri ossium morb., p. 59, 61, 1783, quoted from Berard's 
thesis, p. 7. 

4 Clinique Chirugicale, torn. iii. p. 459, 1830. 



OCCURRENCE OF NON-UNION AFTER ERACTURES. 39 

2d. To the bad quality of their food, and to the brackish 
water that they were forced to drink on this tedious journey. 

3d. To the state of the atmosphere in Syria, that is almost 
deprived of vital air, and loaded with pernicious vapors 
arising from the numerous marshes near which they remained 
a long time. 

The local causes which may hinder the consolidation of 
fractured bones, are various. 

1st. Frequent motion of the part. — This may be owing either to 
indocility and perverseness on the part of the patient, to remov- 
ing patients from place to place after these accidents, or to a 
want of a proper apparatus wherein to confine the fractured 
limb, or of skilful treatment. Too much motion from injudi- 
cious management of the fracture by frequent dressing, or the 
laying aside of splints, and the use of the limb at too early a 
period after the accident, may also give rise to it. Mr. Drum- 
mond, speaking of the little attention shown to severe injuries 
by the natives of New Holland, says: "The same indifference 
is shown to a fractured extremity unless it be a lower one, and 
that of the thigh, consequently no bony union is found to 
take place in such cases; and, indeed, at this period, both 
their sable majesties of the Sydney blacks are found to have 
artificial joints of the forearm." 1 Frequent motion of a frac- 
tured limb is the only cause of want of union mentioned by 
Celsus. Mr. Amesbury 2 considers want of rest to be more 
frequently the occasion of deficient union than any other, and 
considers it to have been the primary cause in almost all the 
cases which he had examined. The opinion that want of 
union is to be attributed most generally to some defect in our 
treatment, is held by Dr. J, E. Barton, 3 Liston, 4 Key, 5 Mac- 
farlane, 6 Malgaigne, 7 and many other surgeons who have 
written upon the subject. Out of 44 cases extracted from the 
table appended to this paper, in which the occurrence of pseu- 
darthrosis has been set down by the authors to some particular 

1 Edin. Med. and Surg. Journ., vol. lvii. p. 118. 

2 Loc. citat., p. 197. 8 Medical Recorder, ix. p. 276, 1826. 
* Lancet, ii. p. 168, 1835-6. 5 Lond. Med. Gaz., iv. p. 262, 1829. 

6 Edin. Med. and Surg. Journ., xlvii. 1837. 

7 Traite des Fractures, torn. i. p. 156, Paris, 1847. 



40 CONTRIBUTIONS TO PRACTICAL SURGERY. 

cause, 22 may, I think, from what is stated, be fairly attri- 
buted to motion in the fracture caused by neglect, or entire want 
of treatment. The information on this point, however, derived 
from the table, cannot be entirely depended upon, little or no 
attention seeming to have been directed to it by most of the 
reporters of the cases. 1 

The following cases are well adapted to show the effect of 
motion in retarding the union of fractures : — 

A healthy seaman of good habits, setat. 45, entered the 
Pennsylvania Hospital February 17th, with a fracture of the 
thigh near its middle part, which had occurred at Porto Eico, 
twenty-one days previously. The accident had been produced 
by a hogshead of sugar rolling over upon his limb, and had 
been properly dressed by a surgeon, soon after its occurrence. 
A day or two after his injury, the vessel to which he be- 
longed sailed for this port, and from that time the treatment 
of the limb was superintended by the captain, the extremity 
being placed in a long fracture-box, extending to the groin, 
and the foot fastened by means of a handkerchief to a cross 
piece at its bottom, the fractured part being at the same time 
supported on its sides by pasteboard splints and thick pieces 
of sail cloth. 

Upon admission, the limb was found to be free from swell- 
ing or excoriation. No callus appeared to have been thrown 
out around the fractured fragments, which admitted of much 
motion. The upper fragment was drawn outwards, and the 
lower was thrown inwards and a little upwards, the limb 
being about one inch shorter than that of the opposite side. 
In order to place the fragments in good position, and make 
moderate pressure over the thigh, Desault's apparatus was 
applied to the limb, though but little extension and counter- 
extension was made, and a full diet with porter was directed. 

By the 14th of March a considerable mass of callus had been 

1 To show how far this is the case, I may mention that in one instance 
(femur) the occurrence of false joint is attributed, by the gentleman reporting 
it, to an attack of cholera morbus, while it is stated at the same time that 
the patient, who was treated with Amesbury's apparatus, was suffered to 
move the limb as often as he liked, and to have his bed made every second 
or third day. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 41 

thrown out about the fracture, but there was still motion ; 
pressure with pasteboard splints, moulded to the limb by 
previously wetting them, and firmly applied by means of a 
roller, commencing at the foot, was made use of, the long 
splints being continued. 

On the 26th, the union seemed firm, and the long splints 
were removed so as to allow the patient to move his limb about 
the bed, the pasteboard being continued. 

On the night of the 28th, he re-fractured his limb at the 
point of previous injury, by turning over in bed during 
sleep, and entangling his foot in the sheet, in consequence of 
which the long splints were again employed. By the 17th 
of April, the limb was found to be again consolidated, when 
the apparatus was removed, and on the 7th of May he left 
the house with a good and very slightly shortened limb. 

Another case of fractured leg of some standing, which had 
occurred and been treated at sea, setat. 28, met with his acci- 
dent on the 7th of November, by a blow from a cable. Both 
bones were fractured near the middle of the leg. He stated 
that ten days after his accident, ulceration over the injured 
part occurred, after which the bone protruded. On the 29th 
of November he arrived here, and was brought to the hospital, 
at which time the extremity of the upper fragment was pro- 
truding, and was removed by my colleague, Dr. Peace, the 
limb being afterwards placed and retained in a good position, 
in a fracture-box. About the middle of January, a small 
piece of bone came away, when the wound soon cicatrized, 
and on the 28th of March he was discharged cured, union 
having been firm for some time previously. 

A third case of delayed consolidation after fracture of the 
leg, treated at sea, occurred in the person of a sailor aged 22, 
who was admitted on the 23d of March. His fracture was in 
the lower third of the limb, and had happened twenty-three 
days previous to admission, from a blow upon the part. The 
bones were quite loose when admitted, and some rising of the 
upper fragment was present. The limb was placed, properly 
supported, in a good position in a box, and a generous diet 
allowed. Pressure by means of pasteboard splints and a 
4 



Ill 



42 CONTRIBUTIONS TO PRACTICAL SURGERY. 

roller were after a short time applied, and by the 14th of 
April union was complete, and a large amount of callus sur- 
rounding the broken bones. The limb was now removed 
from the box, and on the 5th of May he left the hospital 
cured. 

2d. From the fractured ends being widely separate, or from 
their not being kept closely in contact. — "Where there has been a 
loss of substance, the nearer the ends of a fractured bone are 
laid, the easier will consolidation take place, and though 
want of union after fractures may undoubtedly follow the 
first of these causes, yet its occurrence in such cases is not 
constant. The length of bone that may be removed from 
fractured limbs and regenerated, often even under unfavorable 
circumstances, or in debilitated subjects, is truly astonishing. 
In the case of a boy, setat. 12, who came under my care in the 
Pennsylvania Hospital in 1837, two inches of the tibia was 
removed, notwithstanding which he was discharged cured in 
eleven weeks with shortening of the limb of but half an inch, 
the space occupied by the removed bone being filled by a 
firm and even callus. Yan Swieten 1 relates that he saw a 
fragment of the tibia four inches in length, removed after a 
fracture, and replaced at the end of ten months by a firm 
matter without shortening of the limb. Gooch 2 notes a case 
in which five inches of the tibia was lost, and supplied by 
solid bone. Mr. Phillips 3 mentions a young man in whom 
five inches had been removed with a similar result. La Motte 4 
narrates two remarkable instances of a like kind, in one of 
which six inches of the tibia was removed after the accident, 
notwithstanding which the fragments were united at the end 
of eight months without shortening, by a firm callus. Many 
similar cases are to be found in the records of our science, and 
all hospital surgeons must have witnessed such, in a greater 
or less degree. 

The consequence of want of close contact between the frac- 
tured surfaces is well seen in the patella, olecranon, and os 

1 Commentaries, i. p. 514, § 343. 

2 Chirtirgical Works, ii. p. 285. 3 Lond. Med. Gaz., May, 1840. 
4 Traite de Cliirurg., ii. pp. 575-579, 8d edit. 1771. 



OCCURRENCE OP NON-UNION AFTER FRACTURES. 43 

calcis, all of which unite by bone when brought strictly in 
apposition, but, as this is in most cases impossible to effect, 
are found generally united by a fibro-ligamentous matter of 
greater or less length, according as the fragments have been 
more or less widely separated. The difficulty of retaining 
the bones in close contact in oblique fractures, is, in the opin- 
ion of many, a very common cause of deficient bony union. 
To place the fragments in contact in these cases, extension and 
counter-extension is kept up, and often the force exerted is 
in so great a degree as to cause suffering to the patient, and 
is by him, or his attendants, relaxed after the departure of the 
surgeon. At the following visit, displacement is found to 
exist, and in endeavoring to avoid deformity, the surgeon 
extends the limb. Pain ensues, and the apparatus is again 
loosened, and this is repeated until from the constant slipping 
of the fragments over each other, either the ends of the bone 
become smoothed off, and as it were cicatrized, with a large 
and misshapen callus thrown out around each extremity, or 
else bony matter is not deposited in sufficient quantity to sur- 
round the fractured ends, which continue loosely united by 
means of a fibro-ligamentous matter. 

3d. From disease of the fractured extremities. — This is par- 
ticularly the case in compound fractures where necrosis 
follows. In these injuries, if the periosteum be torn off from 
the ends of the bone, these parts at once lose their vitality, 
and the suppuration kept up around the fragments during 
exfoliation hinders union from occurring till a late period, in 
addition to which the long confinement necessitated by such a 
state exerts a noxious influence upon the constitution of the 
patient, and by this means still further retards the work of 
reparation. The case cited by Faivre 1 was of this kind. The 
seat of fracture was in the tibia, and had existed for seven 
months. A portion of the whole cylinder of the bone, one 
and a half inches in length, was found loose and was removed, 
and the ends cauterized with a hot iron ; six months after 
which a perfect cure had taken place. Schmucker 2 also relates 

1 Ancien Journ., lxviii. p. 210. 

2 Verm. Chir. Sclirif., quoted from S. Cooper. 



44 CONTRIBUTIONS TO PRACTICAL SURGERY. 

a case of fractured leg in which necrosis of a portion of the 
tibia followed, and no callus was formed at the end of eight 
months, a sinus remaining on each side of the leg. The sinuses, 
at the end of the time stated, were laid open, and the dead 
pieces of bone extracted, by which means the impediment to 
the formation of callus was removed, and the fracture became 
firmly united in two months. Sometimes, however, the necro- 
sis is only the remote consequence of the injury. Pieces of 
bone are completely broken off at the time of accident, but 
still retain their life, and are embedded in the provisional cal- 
lus, and when the fracture is almost consolidated these lose 
their vitality and act as foreign substances, giving rise to 
inflammation, which destroys in the course of a few days all 
the solidity of the callus, and postpones for a long time the 
cure. Mr. Amesbury 1 mentions his having seen a man with 
a fractured humerus accompanied with necrosis, in which no 
union took place, and the arm was amputated. I have myself 
had occasion to observe a fracture of the leg accompanied with 
caries, in an elderly woman, where union failed to occur, and 
amputation was performed by request of the patient. Hil- 
danus, 2 Duverney, 3 Petit, Heister, 4 and many other authors, 
have recorded similar facts. Interesting cases in which the 
development of hydatids in the medullary canal prevented 
the formation of callus have occurred to Webster, 5 Wickham, 6 
Dupuytren, 7 and a highly interesting case of the same nature 
occurring in the humerus, and cured by the seton, has been 
given by Mr. Crompton of Birmingham. 8 Amesbury 9 has seen 
the same thing follow the existence of abscess in the bone. 
Mr, Arnott 10 amputated the limb of a patient in Middlesex 
Hospital, in consequence of a fracture of the leg which had 
occurred in the situation of a node, and remained ununited at 

1 Loc. cit., p. 197. 2 Opera, 168, cent. ii. Obs. 66. 

3 Mai. des Os. 4 Surgery, Trans. 1763, p. 128. 

5 New Eng. Journ., viii. p. 29, 1819. 

6 Lond. Med. and Pliys. Journ., ii. N. S. 

7 Journ. riebdoin., xii. and ix., 1833. 

* Lond. Med. Gaz., vol. xi., N. S., 1850. 

s Op. cit., p. 197. 10 Lond. Med. Gaz., June, 1840. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 45 

the end of a year: the fibula in this case was firmly consoli- 
dated. The general rule, however, that broken diseased bones 
will not unite, is not absolute. Dr. Peirson 1 has seen repeated 
instances of rapid consolidation in bones so diseased as to be 
broken by a very small degree of force. I had a patient, says 
Sir B. Brodie, 2 " in whom some of the bones had nodes upon 
them, and were much enlarged. A portion of the clavicle 
was enlarged, and much diseased besides. This man broke 
the collar bone through the diseased part. I bound up his 
arm, and it united as soon as ordinary fractures." In the fol- 
lowing case treated by me at the Pennsylvania Hospital, want 
of union was evidently kept up by a necrosed state of the 
inferior fragment, after the removal of which a perfect cure 
was effected. 

The patient was a healthy farmer from Clearfield County, 
Pennsylvania, aged thirty, who was received on the 9th of 
August, 1837. He stated, that on the 29th of May previously 
a loaded wagon had passed over his arm and produced a sim- 
ple fracture, which was dressed by a neighbor, with three 
board splints fastened tightly by a bandage around the injured 
part only. On the second day after its application, in conse- 
quence of violent pain at the seat of fracture, and great swell- 
ing of the hand and forearm, a physician was brought to him 
from a distance of many miles, who removed the dressings. 
Upon removal, the soft parts at the anterior and inner side of 
the arm were found to be mortified, and, in twelve or fourteen 
days afterwards, separated, and left the bone projecting some 
two or three inches. He suffered during this time from severe 
inflammation of the arm, accompanied by fever and a profuse 
discharge of pus; and after recovering in a measure his 
strength, he set off on foot for Philadelphia, where he arrived 
the evening before entering the hospital. The seat of frac- 
ture was found to be just below the insertion of the deltoid 
muscle, and the inferior fragment protruded through an open- 
ing only large enough to admit of its passage. The end of 

1 Remarks on Fractures, p. 38 Boston, 1840. 

2 Lond. Med. Gaz., xiii. p. 56, 1833. 



46 CONTRIBUTIONS TO PRACTICAL SURGERY. 

this fragment was of a yellowish-white color, and deprived of 
periosteum for the space of an inch or more, and not loose. 
No bony union had taken place. There was a small discharge 
of pus from the part, and no pain was experienced on han- 
dling and examining it. A good deal of hardening existed at 
the point of fracture, but it appeared to be rather from thick- 
ening of the different tissues, than from a deposit of callus. 
His general health was good. On the 30th of September the 
projecting portion of the bone was found to be loose, and was 
removed ; after which the wound soon closed, and union be- 
gun to take place. By the 1st of November union was per- 
fectly firm. 

4th. The interposition of foreign bodies between the fragments 
has been generally stated among the causes which may retard 
union. Portions of bone which are completely detached, 
bullets or other foreign substances, sometimes remain between 
the extremities, and by keeping up profuse and long-con- 
tinued suppuration, so debilitate the system as to prevent the 
formation of callus, and give rise to this state. Eossi 1 notices 
a case of ununited fracture of the humerus, amputated by 
him after the resection of the extremities had been unsuccess- 
fully resorted to, in which the cause of non-union was found 
to be a ball contained in the medullary canal a little above 
the false joint. In some rare instances, however, nature 
removes the irritating effects of the foreign body, by giving 
it a covering of dense fibrous structure. A remarkable 
instance in which this happened after fracture of the femur, 
is reported by M. Yogelvanger. 2 Two years after the acci- 
dent the patient died, and M. V. found a piece of iron thirty- 
five lines in length, and five in breadth, completely sur- 
rounded by a deposit of callus. 

Slips of muscle, or of tendinous matter interposed between 
the fragments, have also been stated as causes of want 
of union. That in some instances these parts are found 
lying between the fractured extremities there is no doubt, 

1 These sur les Resections, by M. Roux. 

2 Gaz. Medicale, p. 445, 1838. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 47 

but that it ever proves in itself a cause of non-union, I am 
not disposed to admit. In all of the instances in which I 
find it mentioned as having existed, it is also stated that the 
fracture has been oblique, and the fragments more or less 
separated from each other. When this state of things exists, 
any soft parts in the neighborhood of the fracture are neces- 
sarily forced into the space between the bones, and so remain 
until a proper position is given to the limb and the fragments 
perfectly reduced; and where, from the size of the intervening 
part, this cannot be at once done, the mere continued pressure 
of the ends of the bone would, in a very short time, if pro- 
perly adjusted, either cause its absorption, or else cause it to 
take on the ossific action. The interposition of any soft parts 
between the ends of a fractured bone, is justly regarded by 
Mr. Key 1 as a mere excuse for the occurrence of non-union. 
"It is the duty of the surgeon," he observes, "when he 
examines into the nature of the accident, and places the limb 
in splints, to ascertain that the fractured ends grate together; 
and if muscle is interposed, to make extension in order to 
disengage the broken extremity." The case mentioned in the 
Dictionary of Cooper, on the authority of Sir James Earle, 
is often quoted to show the possibility of muscular substance 
forming an impediment to the union after fractures. He says, 
"I have seen a woman, under Sir James Earle, in the above 
hospital (St. Bartholomew's), whose os brachii did not unite, 
though it had been broken several months. Every attempt 
to move the bone occasioned excruciating torture. The 
woman died of some illness in the hospital ; and, on dissect- 
ing the arm, the cause of the fracture not having united was 
found to arise from the upper sharp pointed extremity of the 
lower portion of the broken bone having been forcibly drawn 
up by the muscles, and penetrated the substance of the biceps, 
in which it still remained." From this it is clearly evident 
that the fracture was oblique, and the fragments much dis- 
placed; and this want of apposition in the fragments is surely 
alone a sufficient cause for the non-union, without seeking for 

1 Lond. Med. Gaz., iv. p. 264. 



W\\ i 



48 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



it in the interposition of muscular fibres between the frag- 
ments. Besides, it is well ascertained that muscles, as well as 
all the other parts surrounding a fractured bone, contribute 
more or less to the formation of the callus. An interesting 
preparation going to support this view, and much to the point 
in this particular matter, is mentioned in the Dictionnaire de 
Medecine, xiii. art. Fract., 2d ed., as having been presented to 
the Anatomical Society of Paris, in which the fragments of a 
clavicle, separated to the extent of an inch bj the subclavian 
muscle, were united together very solidly by two bridges of 
newly-formed bone, in the centre of which the muscle, itself 
ossified, was imprisoned. 

5th. Tight bandaging. — That a tight bandage may prevent 
the restorative process from taking place there can be no 
doubt. Duverney 1 thinks nothing in simple fractures so 
much opposes the formation of callus as a too tight bandage. 
Pare 2 and Wiseman 3 also caution us in regard to its employ- 
ment. Sir B. Brodie explains its modus operandi, by sup- 
posing that the fracture does not receive a sufficient quantity 
of blood to allow of the process to go on; but M. Malgaigne, 
with more reason, attributes it to the pressure preventing the 
deposit of the provisional callus. In support of the view of 
the latter it may be remarked, that Troja long since satisfied 
himself by experiment, that moderate compression in no way 
interferes with the process of reunion after fractures, but 
showed that a bandage tightly applied, without, nevertheless, 
being so much drawn as to cause any serious accident, pre- 
vented the formation of the provisional callus and its conse- 
quent consolidation. 

6th. The long -continued use of cooling applications, by keeping 
down vascular action in the fractured part, is ordinarily given 
as one cause of tardy union. These applications should never 
be continued after the subsidence of the acute inflammatory 
symptoms. By Mr. Amesbury, diminished action from the 
too long continuance of sedative or cooling lotions, is regarded 



1 Diseases of the Bones, trans, by Ingham, p. 171, 1762. 

2 Works, trans, by Johnston, p. 379, 1649. 

3 Chirurgical Treatises, ii. p. 256, 5th ed. Lond. 1719. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 49 

as a frequent cause of tardy union. 1 Dupuytren regards them 
in the same light. 

7th. The too early use of a fractured limb sometimes causes 
absorption of the callus to such an extent as to permit of 
motion in the part ; and if in such instances the moving about 
is continued, the friction kept up between the ends of the 
bone causes them to become rounded, at the same time that 
the surrounding tissues become thickened, and form a false 
joint. 

Though the above oftentimes cause the want of firm union 
after fractures, yet it must be confessed that want of consoli- 
dation occurs in some instances, without our being able to 
trace it to any particular cause. One of the most authori- 
tative writers on the subject of ununited fractures, is unwill- 
ing to admit that in these cases, a cause cannot always be 
found. On this point, he thus expresses himself: "I have 
examined fifty-six cases of non-union, exclusively of those 
which I have witnessed in the neck of the thigh-bone, 
olecranon, and patella. The constitutions of three of these 
were decidedly bad ; another had been much reduced by 
cholera, during the recent state of the fracture. The remain- 
ing fifty-two, apparently, possessed constitutions, and enjoyed 
health equal to the most vigorous and healthy individuals 
that came under observation." " In these cases, with the ex- 
ception of two which occurred during pregnancy, where con- 
stitutional causes might, under any treatment, have operated 
in a measure so as to retard the union, I think the cause was 
purely local ; and for the most part, if the treatment had been 
such as to secure the fractured parts in proper apposition, and 
in a state of quietude, the fractures would have united at an 
early period." 2 The experience here given is valuable, though 
allowance is to be made for any mere opinion on this subject 
from its author, inasmuch as this theory of the cause, or mode 
of production of ununited fractures, was brought forward to 
support arguments for the use of his peculiar apparatus in the 
treatment of these accidents. Equally good observers, and 

1 Op. citat., p. 198. 2 Amesbury, loc. citat., p. 202. 



50 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



careful practitioners, differ in "belief from him, and that it 
sometimes happens that no firm union will take place in per- 
sons enjoying apparent perfect health, even when regularly 
and judiciously treated, must be admitted. An instance of un- 
united fracture is mentioned by Mr. Samuel Cooper 1 which oc- 
curred in a strong and robust man, whose chief peculiarity 
seemed to be his indifference to pain, where the ends of the 
humerus were cut down to, turned out, and sawn off by Mr. 
Long, in St. Bartholomew's Hospital, and the limb was after- 
wards put in splints, and taken the greatest care of; but no 
union followed. He also notices another case of a broken tibia 
and fibula, occurring in a subject who was a complete instance 
of hypochondriasis, which remained disunited for about four 
months ; but afterwards grew together. M. Sanson 2 cites three 
cases of fractures, one of the leg and two of the thigh, that 
required from five to ten months of treatment before union was 
perfect ; and two cases of false joints in the thigh, in which it 
was impossible to attribute this state of things to any appreci- 
able cause. Latta states that he had met with three instances 
of fractures purely transverse, in which, notwithstanding all the 
care that could be taken, no callus was formed. 3 Euysch and 
"Van Swieten have reported several like facts, and other cases 
might readily be brought forward. 

So often indeed, does non-union occur after the most regu- 
lar treatment, that we should be cautious in ever attributing 
this state of things to any fault of the surgeon. That want of 
care in the treatment on the side of the practitioner, or rest- 
lessness on the part of the patient, does not hinder the forma- 
tion of callus in large quantity, must have been noticed by 
every one. In bad compound fractures, the large discharge 
of matter from the wound not unfrequently requires that the 
limb be daily moved, and the fragments are consequently 
much oftener disturbed than occurs in the treatment of simple 
fracture, and yet false joint is not as frequent in the former as 
the latter class of cases. How often do we see cases that have 



1 Dictionary, ed. 1838, p. 551. 

2 Diet, de Med. and Chir. Prat., iii. p. 494. 

3 System of Surgery, iii. p. 362. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 51 

been carelessly treated, or even entirely neglected, where 
union, though attended with deformity, takes place ? How 
often where two bones existing in the same limb have been 
fractured, do we find that one will unite and the other not? 
How many cases too have been observed, where more than 
one fracture has existed in the same individual at the same 
period, and where, though all be equally well treated, want of 
union will follow some one of them? One instance I have 
seen recorded where the humerus was broken in two places, 
the upper one of which united firmly, and the other did not. 
If non-union depended generally upon want of perfect rest in 
the injured part, the bones that are with most difficulty re- 
tained in apposition after fracture, are those in which we 
should expect most frequently to meet with it. The clavicle, 
comparatively speaking, is rarely the seat of ununited fracture, 
and yet did it depend upon mobility, that bone of all others, 
is the one we should find most frequently affected with it. 
The ribs we daily see well united after fractures, despite the 
constant motion to which they are subjected in respiration. 
In animals, Sir B. Brodie 1 asserts, that he has tried, over and 
over again, to prevent union by giving motion to the broken 
bones several times a day, but has never succeeded, and, in- 
deed, thought that union seemed to go on more rapidly where 
the limbs were thus exercised than when they were not dis- 
turbed. Union, however, we know takes place with great 
facility in animals, and the knowledge of this fact proves of 
itself nothing conclusively in regard to fractures in man ; but 
surely the known uniformity of nature's laws, when taken in 
connection with the facts we have just adduced, should make 
us pause before positively asserting that motion is always the 
cause of ununited fractures — more especially when, as is some- 
times the case, an opinion is required which may irreparably 
injure a fellow practitioner. Causes may be suggested for 
this state of things, some of which may seem plausible, or be 
shown to be true with regard to particular instances, but in 
many cases its occurrence cannot be satisfactorily accounted 

1 Loc. cit., p. 57. 



52 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



for. In the words of Sir James Paget, 1 it "sometimes appears 
like a simple defect of formative power ; a defect, which, I 
believe, cannot be explained, and which seems the more re- 
markable when we observe the many changes which may at 
a later time be effected, as if to diminish the evil of the want 
of union." That the state of the constitution has considerable 
influence over the process of reparation in fractured bones, 
none can deny — where the lancet has been largely used after 
the accident, where patients are much debilitated, or are labor- 
ing under constitutional diseases, the process may be retarded ; 
but where the peculiarity of constitution which renders the 
vessels of the injured part incompetent to furnish bony matter 
does not exist, we find generally the deposit of callus to take 
place, upon this morbid state of system being removed. 
Schmucker 2 found the formation of callus, even in the most 
simple fractures, sometimes delayed eight months, and in one 
example, more than a year; but all the patients were un- 
healthy. Even after a fractured limb has become perfectly 
firm, and is surrounded by a large mass of callus, it is possible 
for it to become softened, or even entirely absorbed, during 
an attack of general fever, erysipelas, or other acute affection. 
I have in two or three instances witnessed the first of these 
effects produced by attacks of erysipelas in compound frac- 
tures, when the disease has prevailed generally in the wards 
of the Pennsylvania Hospital; and in one instance of simple 
fracture have seen a rapid absorption of a large callus, which 
had produced firm union of a fracture of the lower third of the 
leg, occur without any apparent cause, to such an extent, as 
to render the fragments very movable, and necessitate a 
renewal of the treatment. This absorption, or softening of 
the callus, has been observed by Mead, 3 in a sailor, attacked 
by scurvy, in whom, three months after firm union of a frac- 
tured clavicle, the callus became softened and gave way; in 
this case the general affection is stated to have retarded for 
more than six months any new union. In speaking of the 



1 Surgical Pathology, Lond. 1863, p. 193. 

2 Vermischte Cliir. Scliriften., quoted from S. Cooper. 

3 Medical Works, p. 442. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 53 

ravages of the scurvy during his voyage, Lord Anson makes 
mention of a man on board the Centurion, in whom " the 
callus of a broken bone which had been completely formed 
for a long time was found to be dissolved, and the fracture 
seemed as if it had never been consolidated." Another like 
instance has been recently observed by Dr. Budd. 1 We find 
recorded by Desault, 2 the case of a fractured femur occurring 
in a woman, aged 82, where consolidation took place by the 
seventy-fifth day, but in whom, two months after, death oc- 
curred from severe diarrhoea, and the callus was found com- 
pletely softened. Morgagni 3 quotes from Salzmann, the case 
of a soldier with fractured tibia, in whom union had become 
so firm as to allow of his walking upon the limb without diffi- 
culty ; but during an attack of fever, eight months afterwards, 
the callus was noticed gradually to disappear, so that the ends 
of the bone became separated. After convalescence, the parts 
again became firm. Dr. Schilling has seen the callus deposited 
around the ends of a fractured femur, which had become so 
firm as to allow the patient to bear some weight upon the 
limb, completely absorbed during an attack of typhus abdom- 
inalis. Ten daj^s after the symptoms set in, callus could no 
longer be felt, and the bones moved as easily upon one an- 
other as immediately after the reception of the injury. In six 
days more the patient died. The examination showed no 
trace of callus, the broken surfaces were bloody, like those in 
a recent fracture, and were surrounded by a sac-like mem- 
brane, which contained some black bloody fluid. 4 Mr. Mantell 
has published the case of a youth, aged seventeen, 5 who, some 
weeks after the perfect cure of a fractured leg, was seized 
with a severe attack of fever, and upon first leaving his bed 
after the subsidence of it, the limb bent under him in conse- 
quence of the callus having become soft, and giving way. 
As recovery from the fever proceeded, new callus was formed 
and reunion of the fracture was effected, though with much 

1 Tweedie's Cyclopedia— Art Scurvy. 2 Journ. de Cliirurg., i. p. 243. 
3 French Translation, ix. p. 159, Paris, 1820. 
* British and Foreign Med. Review, 1840. 
5 Lancet, i. 1841-2, p. 58. 



54 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



deformity of the limb. In the thesis of M. Bdrard, I find 
another instance, quoted from Bonn, where fever with inflam- 
mation and gangrene, occurring in an old man, who had suf- 
fered from fracture of the femur that was firmly united, pro- 
duced absorption to such an extent, as to allow the fragments 
to become movable one upon the other. Dr. Penel, 1 Surgeon 
to the Civil and Military Hospital at Abbeville, furnishes the 
case of an elderly man with fractured thigh, in whom, on the 
fortieth day, union being solid, the dressings were removed, 
and the limb laid on a bolster; but suddenly the callus was 
destroyed, and it was necessary to make continued extension 
to reduce the fractured bones : at the same time the urine was 
observed to deposit a considerable quantity of a greenish sub- 
stance, which on examination was found to be phosphate of 
lime. The fracture seemed again to consolidate, the urine 
however remained the same, and was passed in a greater 
quantity. Two months after the fracture, the callus appeared 
a second time firm. The dressings were continued twenty 
days longer; but two days after their removal, the extremities 
of the fracture separated, and it was necessary again to make 
the reduction. He now gave the patient 3ss of nitric acid 
daily, when the urine became clearer, and four months after 
his first reception the dressings were removed and the limb 
found to be firm. From some cases published by M. Guyot, 2 
it appears that an inflammatory action in the callus alone, 
unaccompanied by any other affection, and ensuing several 
weeks after the accident, occasionally produces softening and 
absorption of the newly formed bone, and ultimately disunion 
of the ends. Duverney, 3 Malgaigne, 4 Wardrop, 5 Kirkbride, 6 
Laugier, 7 Guersant, 8 and Vidal, have all witnessed cases of 
absorption of the callus, in acute local disorders. This soft- 
ening, or absorption, however, affects the provisional callus 
alone, and is consequently seen only in the first few months 



1 Lond. Med. and Phys. Journ., xiv. p. 29, 1805. 

2 Arch. Gen. de Med., Feb. 1836. 

3 Op. citat., preface. * Lancette Francaise, iii. p. 217, 1830. 

5 Med. Cliir. Trans., v. 6 Amer. Journ. of Med. Sciences, xv. 1835. 
7 Des Cals Difformes. 8 Gaz. des Hopitaux, Dec. 1842. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 55 

that follow a fracture ; at a later period, when the definitive 
callus is completely formed, the bone becomes more dense and 
firm than it originally was, and is never absorbed. The fol- 
lowing well-attested case, in which not only the callus result- 
ing from a fractured, humerus but the whole bone was slowly 
absorbed, is, we believe, without parallel in the records of 
surgery. 

Mr. Brown, residing in Derne St., Boston, aged 36, when in 
his eighteenth year fractured the right humerus near the mid- 
dle. Under the care of a judicious surgeon, a reunion was 
favorably going on ; but, before the curative process had been 
completed, the patient had another fall, and again broke the 
arm at the seat of the old fracture. Notwithstanding every 
care, the divided extremities would not adhere ; and, to the 
surprise of the medical attendant, the shaft of each part of 
the divided bone began to diminish in size, and shorten in 
length. By a gradual action of the absorbents, the whole of 
the arm bone, between the shoulder and the elbow, was at 
length completely removed, and that, too, without any open 
ulcer, so that not a vestige of it was left. Mr. B. now, after 
many years, presents the spectacle of one short and one long 
arm. The right forearm and hand are of a size to correspond 
with the sound one on the left side, and under certain circum- 
stances are equally as strong. Ordinarily the right arm 
swings hither and thither, like a thong with a weight at the 
extremity ; for the forearm and hand, with reference to the 
division above the elbow, constitute a pendulum, oscillating 
according to the movements of the body. Although it is 
impossible to push with the defective arm, he can draw a bur- 
den towards himself with it as strongly and tenaciously as 
with the other; and in so doing, the muscles are elongated, 
so that the arm is extended to its original length ; when the 
resistance is removed, the muscles instantly shorten them- 
selves about six inches. To show the perfect non-resistance 
of the apparatus of muscles, arteries, veins, and nerves in the 
soft, boneless space, we saw him twist the palm of the hand 
twice round, which consequently presented the strange ano- 
maly of having all the apparatus of the arm twisted like the 



56 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



strands of a rope. 1 The subject of this singular case died in 
the Boston Lunatic Asylum, of pneumonia, on the 11th of 
February, 1871, at the age of 70. He had been an inmate of 
the institution at intervals for four years and three months, but 
except in mental condition, was, as he had always been, in 
excellent general health, with no local affection of his osseous 
system except the arm alluded to, and capable of a very con- 
siderable amount of manual labor. For four years after his 
fracture Mr. B. did no work, but the process of absorption 
covered a period of twelve years, at the end of which, time 
the limb had attained a condition in which it permanently 
remained until the day of his death. He could hoe, rake, 
shovel, sweep, cut wood, carry a large pail of water, hold a 
knife at the grindstone, and write a good hand. By twisting 
the upper part of his arm, he could use his fingers well enough 
to tie his neckhandkerchief. The muscular power of the arm 
was very considerable. The dissection, which is minutely 
described by Dr. C. B. Porter, showed all traces of the hume- 
rus to be obliterated, except its two extremities, the lower one 
being an inch and a half long, and the remains of the upper 
extremity consisting of a thin auricular-shaped plate of bone, 
two inches long and one wide, in close relation with the arti- 
cular cavity, but presenting no articular surface. 2 

Cases of pseudarthrosis sometimes occur which occasion so 
little inconvenience as scarcely to interfere with the use of 
the parts in which they may be situated; and under such cir- 
cumstances, it is more than doubtful whether any operative 
means should be recommended for their cure. In the Nou- 
velles de la Republique des Lettres, of Bayle, a case is recorded 
by Sylvestre, in which an ununited fracture of the forearm, 
four inches above the wrist, in no way prevented good use of 
the limb. Sue 3 mentions a case of fractured femur which 
never united, where during a period of eleven years the 
patient enjoyed good health, and walked about easily with 
the aid of a cane. Mr. Crompton 4 saw an ununited femur, 

1 Boston Med. and Surg. Journ., July, 1838, p. 368. 

2 Boston Med. and Surg. Journ. for October 10, 1872. 

3 Maladies des Os. i Lond. Med. Gaz., vol. xi., N. S., 1850. 



iy» 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 57 

close above the knee-joint, where the man could walk pretty 
well by the aid of a strong leather case, and on that account, 
as well as because of the close proximity of the fracture to 
the joint, recommended nothing to be done. Kuhnholtz 1 has 
given an instance in which an ununited fracture, situated in 
the thigh, interfered but little with the use of the limb. MM. 
Sanson 2 and Yvan 3 have seen like cases. A patient came un- 
der the notice of M. Cloquet, 4 in whom the upper fourth of the 
humerus had been lost, without in any way interfering with 
the motions of the arm. Another instance in the same bone 
in which all the motions of the arm could be performed, though 
it was weakened and the patient was not sure of his motions, 
is furnished by Brasdor. 5 M. Yelpeau 6 noticed some years 
since, at La Pitie, a man with an ununited fracture of the clavicle, 
in whom all the movements of the arm were executed without 
difficulty. M. Gras 7 gives an instance of an ununited fracture 
of both bones of the forearm, at the inferior part, from gun- 
shot, which gave so little inconvenience that no operation was 
attempted, and Mr. Marshall [On Enlistment) mentions the 
instance of a recruit with a false joint in the same part, who 
passed the usual examination as to his physical condition. 
Horeau 8 has furnished a case situated in the lower jaw, in 
which, although mastication was somewhat affected, yet was 
so little annoying, that the patient was not willing to undergo 
any treatment for it. Mr. Syme 9 has seen want of consolida- 
tion in the humerus and forearm, where the fracture was 
transverse, accompanied with very little inconvenience. I 
have myself seen a young Irish woman with an ununited 
fracture of the clavicle, in which, although great motion 
existed between the fragments, so little inconvenience was 

1 Journ. Complementaire, iii. 

2 Velpeau, Medecine Qperatoire, i. p. 599, eel. 1839. 

3 Archives Gen. de Med., xix. p. 619. 

4 Archives Gen. de Med., xix. 

5 Mems. de l'Acad. de Chirurg., torn. v. p. '381, 8vo. 

6 Gone. These, No. 218, 1835. 

7 Journ. de Med. Chir. and Pharm. in 40 vols. viii. 

8 Journ. de Med. Chir. and Pharm. x. 

9 Edin. Med. and Surg. Journ., July, 1835. 
5 



58 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



experienced, that it was not judged proper to resort to any 
treatment for it ; and in 1839 a case of false joint in the radius, 
two and a half inches above the wrist, came under mv notice, 
where the patient enjoyed excellent use of the member, and 
notwithstanding some deformity, was able to work at his trade 
(that of a tailor) as well as if no accident had happened ; and 
a few years since was consulted by a muscular man with a 
non-united humerus at the insertion of the deltoid, which 
allowed of good, though not perfect, use of the member with- 
out any artificial support. 

Even in cases where the want of bony union in fractures 
has not permitted the patient to make use of the limb, we 
often find that by the employment of simple means the defect 
may be rendered supportable. M. Troschel 1 mentions three 
instances in which, by the application of tin splints fitted to 
the limbs, the persons were enabled to walk without difficulty. 
Monteggia (iv. p. 28) relates the case of a monk in whom 
existed a non-consolidated fracture of the middle of the fore- 
arm, and who, by means of an appropriate apparatus, could 
make use of it for all ordinary purposes. Briot 2 notices the 
cases of two soldiers in whom fractures of the arm had not 
become consolidated, where well-padded splints of sheet-iron, 
so formed as to surround the limb, diminished considerably 
the inconvenience resulting from the non-union, and in an- 
other case of a laborer, which had existed for twelve years, 
good use of the member was obtained by like means, M. 
Velpeau 3 examined an ununited fracture of the thigh in a 
female, who, with the aid of a clumsy apparatus, continued to 
make good use of her limb. Delpech 4 has seen a workman 
with a non-consolidated fracture of the femur, who, by means 
of a case for the thigh, was enabled to pursue his usual em- 
ployments. Mr. Linton 5 furnishes the case of an Arab sheik, 
affected with a fracture of the right humerus, accompanied 
with great loss of bone, that had never united, in which a cir- 



1 Journ. des Progres, x. p. 257. 

2 Hist, de la Chirug. Militaire, 1817. 

4 Diet, des Sci. Medicales, iii. art. Cal. 

5 Lond. Med. Repository, Feb. 1824, p. 93. 



3 Op. cit., ii. p. 582. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 59 

cular silver tube, six and a half inches in length, was worn 
with ease, and permitted him to do good service with his 
sword. Dr. Betton, of Germantown, mentioned to me an in- 
stance which came under his notice, in which no union had 
occurred after a fracture of the humerus, where a pasteboard 
splint, made so as to surround the arm, was worn with such 
good effect as to allow the man to apply himself to his usual 
employment. In his retrospective address in surgery, deliv- 
ered at Liverpool in 1839, * Mr. James mentions, that having 
failed in obtaining union of the bones of the upper arm by 
excision of their ends, in a case where a seton could not have 
been passed, he had recourse to an external apparatus, which 
appeared to answer the purpose of giving stability to the limb 
so well, that he " should feel very reluctant to undertake a 
severe operation again for this defect, unless on further trial 
the apparatus was not found to succeed." Larrey 2 even goes 
so far as to recommend in all cases of fracture, where the 
usual means are insufficient to effect consolidation, that they 
be left to nature. The patients, he says, accustom themselves 
to this infirmity, of which the effects diminish with time and 
exercise, and they finish by being able to use the affected limb 
with the aid of a pasteboard splint to envelop it; three cases 
are related by him, all of whom, despite the existence of false 
articulations in the arm, were able to perform the ordinary 
duties of soldiers. More lately, the same surgeon has exhib- 
ited to the Academy of Surgery 3 an invalid affected with a 
disunited fracture of the femur in its middle, of several years' 
standing, where, although the member was shortened, and the 
fragments very movable, the patient, by means of a high-heeled 
shoe, made use of his limb without the aid of crutches. In- 
stances have occurred in the leg, where, one of the bones only 
being broken and remaining disunited, the other has become 
enlarged to such a degree as to support well the whole weight 
of the body. A very remarkable example of this sort, in 
which the tibia remained ununited, while the fibula, which 

1 Provin. Med. and Surg. Trans., viii. 2 Clin. Chirurg., iii. p. 461. 
3 Diet, de Medecine, xiii. p. 492, 2d ed. 



60 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



had remained perfect, increased exceedingly in size, and per- 
formed the office of the tibia in supporting the body, is men- 
tioned by Dr. South 1 as having been in the museum of St. 
Thomas's Hospital, and Sir Astley Cooper, in his work on 
Fractures and Luxations, figures a case of a similar kind. 
Such instances are rare. 

In the majority of cases, however, the extremities affected 
by pseudarthrosis become almost useless, and resort to cura- 
tive means is demanded by the patient. As late as 1763, 
Legrand reported to the Academy of Surgery of France, three 
observations of want of union for which he was at a loss to 
suggest any operative procedure, 2 and up to the time of White, 
in 1760, so few were the cures by the methods then in use, 
the majority of persons laboring under these affections had 
only the choice of retaining a useless limb, or of having it 
removed by amputation ; but now, thanks to the progress of 
our science, many different methods are offered for their 
relief, of which the following are the principal : — 

1st. Friction, or rubbing the extremities of the bone against 
each other.. This method is mentioned by Celsus, and appears 
to have been that usually adopted by the surgeons of his 
time. " If the fracture be of long standing, the limb is to be 
extended, in order to produce a fresh injury : the bones must 
be separated from each other by the hand, that their broken 
surfaces may be rendered uneven by the grating against each 
other ; and if there be any fat substance, it may be abraded, 
and the whole reduced to the state of a recent accident; yet 
great care must be employed, lest the ligaments or muscles be 
injured." 3 John Hunter recommended it. In some cases 
where the union is delayed, the mere removal of the splints 
and leaving of the limb free and without apparatus of any 
kind will produce sufficient action in the ends of the bone to 
bring about firm union. Sometimes the friction is made by 
seizing the extremities of the bones, and strongly rubbing 
one against the other ; this is to be done daily until the parts 



1 Otto, loc. cit., p. 224. 2 Journ. de Desault, torn. ii. 

s Liber 8, Cap. 10, Lee's Trans., ii. p. 422. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 61 

"become painful, when the ordinary apparatus is to be applied 
for the purpose of keeping the fracture in a state of perfect 
rest. At the end of ten or twelve days the limb should be 
examined, and if union is not excited, or at least some stif- 
fening have been produced, the process is to be again re- 
peated. Another method, often resorted to in the lower 
extremities, of making frictions of the ends of the bones, 
consists in enveloping the limb in pasteboard previously 
softened, a leather case, or other suitable apparatus, and then 
suffering the patient to move about and bear weight upon it 
as usual, in order that the friction, the " stimulus of exercise," 
should bring about such a degree of irritation as would lead to 
the deposit of callus. Mr.' White of Manchester in 1768 was 
the first to employ friction by pressure and motion. Being 
consulted by a patient in whom the femur had not united at 
the end of five months, he advised the use of a case of strong 
leather, properly lined and stuffed, and so made that when 
laced it enveloped the whole thigh, and kept the fragments 
extended and in apposition. After its application the man 
was made to get up and endeavor to walk by the help of 
crutches. After the apparatus had been worn for some time, 
the thigh began to swell, and, about three months after the 
treatment was begun, a large abscess appeared and was 
opened, by which time perfect union had taken place. 1 In 
three instances Mr. Inglis employed a case very similar to 
that of White ; in one of these the femur was interested, and 
some months after the patient's discharge from the hospital 
wearing it, "he returned with the case in his hand to restore 
it, and to show that by its means he had been completely 
cured." 2 Troschel 3 has described and figured an apparatus 
for the same purpose invented by Baillif, a Prussian mechani- 
cian, and details three instances in which it was used ; in one 
of them, where the false joint was in the middle of the thigh, 
the patient could walk, with the aid of a cane, twenty miles 
a day. Several cases of delayed consolidations, where a 

1 Cases Surgery, p. 76, 1770. 

2 Edin. Med. and Surg. Journ., vol. i. 1SC5. 

3 Jouru. des Progres, 1828. 






62 CONTRIBUTIONS TO PRACTICAL SURGERY. 

similar treatment was resorted to, have been also reported 
by Dr. H. H. Smith of this city. 1 A state of perfect rest, 
however, it should always be remembered, is necessary to the 
proper and speedy union of fractured bones ; and this fact 
should not be forgotten in the application of the treatment 
here mentioned, to the cure of ununited fractures, so that, so 
soon as the proper degree of irritation is once effectually 
produced, the patient should be placed in a state of quietude, 
and his affection treated as a recent injury. The continuance 
of exercise, or frictions, after the occurrence of irritation, 
would retard rather than accelerate the firm union of the 
fragments. 

2d. Blisters applied to the seat of ' fracture were proposed by 
Mr. Walker, of Oxford, in 1815. 2 This method is peculiarly 
adapted to cases which are tardy in uniting. They appear to 
act by exciting the periosteum, and parts about the fractured 
ends, to increased action; and the same effect may be pro- 
duced by an attack of inflammation in the limb. An interest- 
ing instance of the effect of this latter is given by Seerig. 3 
The patient, who had refused all treatment, was seized, without 
any apparent cause, with erysipelas of the limb, which pro- 
duced its consolidation. Mr. Wardrop 4 mentions a case of 
fractured humerus, where union went on rapidly after con- 
tusion of the part, although there previously seemed to be no 
disposition towards it. Dr. Kirkbride 5 also mentions a case 
in which an attack of erysipelas, after the passing of a seton, 
appeared to hasten considerably the consolidation of the bone. 
Another instance, in which the inflammation produced by an 
accident was sufficiently great to cause consolidation of an 
ununited fracture, is reported by Mr. Amesbury. 6 "A gentle- 
man had a fracture in the thigh, in which no union could be 
produced. Several months after his accident he was thrown 

1 Amer. Journ. Med. Sci., vol. xxix. N. S. 1855. 

2 Lond. Med. and Phys. Journ., xxxii. p. 470, 1815. 

3 Quoted from Archives Generates for Jan. 1839, p. 105. 

4 Med. Chir. Trans., v. 1814. 

5 Amer. Journ. of the Med. Sciences, No. xxxiii. 1835. 

6 On Fractures, 2d ed. 1829, p. 210. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 63 

out of his gig, and the wheel passed over the limb at the 
fractured part. He was confined after the second accident, 
which was followed by high inflammation ; and now the 
fractured bone united." 

Sir B. Brodie 1 asserts that he has found very great benefit 
from the use of blisters, in cases which are not of long stand- 
ing. In cases of tardy union, to which they are particularly 
applicable, I have, in more than one instance, witnessed a very 
rapid deposit of callus after the application of blisters to the 
seat of fracture. From the nearness of the tibia to the sur- 
face, their employment is peculiarly adapted to fractures of 
this bone, and are much more likely to prove successful in it, 
than where the bones are deeply covered with soft parts. 
Even in the superficial bones, however, they sometimes fail. 
An instance of this kind, occurring in a lady who had a 
fracture of the tibia at the small of the leg, in which they 
were tried for a long time without benefit, is mentioned by 
Amesbury. 2 Mr. Walker made use of blisters of small size, 
and repeated their application as often as five or six times. 
Velpeau recommends that they be sufficiently large to sur- 
round the limb. In those instances in which I have witnessed 
their employment, they were made of such size as to cover 
completely the seat of injury. Sinapisms are an equally 
efficacious means of inducing irritation, and on some accounts 
are preferable to the use of blisters. 

3d. Iodine. — The treatment of non-union after fracture, by 
the application of iodine to the injured part, was first pro- 
posed by Mr. Buchanan, of Hull, in 1828. 3 He applied it in 
the form of tincture, by daily painting over with a small 
brush the parts covering the false joint. In the case reported 
by Mr. B., the Hunterian method was, at the same time, re- 
sorted to, and a perfect cure was obtained in four months, 
though the Hunterian method alone had been unsuccessfully 
tried previously to the application of the iodine, for six 
months. The same remedy has been since made use of with 

1 Lond. Med. Gaz., xiii. p. 57, 1833. 2 Loc. citat., p. 212. 

3 On a New Method of Treatment for Diseased Joints and the non-union 
of Fractures. London. 



64 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



good results by Mr. Crosse 1 and Dr. Willoughby. 2 According 
to Oppenheim, 3 it has also been successfully repeated by 
Trusen, in Germany. The efficacy of the iodine in these 
cases can only be owing to its stimulating properties; and in 
some instances of slow union, where blisters are objected to, 
it might be worthy of trial. 

4th. Compression and Pressure and Rest. — Mr. Inglis, in 
1805, 4 adopted this plan of treatment. In his ease a consider- 
able degree of pressure was made over a tin-plate, placed 
over the seat of fracture, by means of a roller. In this 
instance, however, as also in one which occurred several 
years previously to White, in which nearly a similar plan of 
treatment was pursued, the pressure was combined with 
frictions, the patients being permitted to move about after the 
application of it. Pressure, conjoined with perfect rest, or, 
as it has been termed, still pressure, was first proposed by 
Mr. Amesbury, and has been highly lauded by Dr. "Wright, 
of Baltimore. In some instances it has been produced by 
means of the peculiar apparatus of the former of these 
gentlemen for the treatment of fractures, while in others, it 
has been applied by means of a tourniquet passed around the 
seat of injury, the part being previously enveloped in splints 
or the immovable apparatus. We are totally without facts 
to show that pressure and rest alone are sufficient to bring on 
such a degree of action as is necessary to produce union 
where the pseudarthrosis has been of long-standing, and is 
itself unaccompanied by inflammation of the periosteum or 
parts about. It cures solely by immovability, and is conse- 
quently only applicable to such cases as occur within the 
period in which the permanent callus is produced. 

In the following case, treated by me at the Pennsylvania 
Hospital, a rapid cure was effected by this mode of treatment. 
The patient, aged 50, was admitted Sept. 14th, 1839, with a 
fracture in the lower third of the femur of seven months' 



i Lond. Med. Gaz., vi. p. 512, 1830. 

2 Trans, of Med. Soc. of State of N. York, i. p. 76, 1834. 

3 Loc. citat., p. 3. 

1 Edin. Med. and Surg. Journ., i. 1805. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 65 

standing ; the leg of the same side, which had also been 
fractured by his accident a little below the knee, had firmly 
united. The lower part of the thigh was enlarged, owing to 
the callus thrown out around the seat of injury, and was 
much bent outwards and shortened. He was unable to bear 
his weight upon the limb, and upon attempting to do so the 
motion of the lower "upon the upper fragment was very 
evident, both to the patient and observer. Strong extension 
had no effect in bringing down the limb to its natural length, 
and the treatment was directed with a view of producing 
union by compression and rest. For this purpose, a roller 
being first applied, strong pressure was made over the pro- 
jecting portion of the bone by means of a bandage secured 
to a well-padded long splint placed upon the inner side of 
the limb, the bandage being reapplied every few days. At 
the end of a month the deformity was evidently less and the 
union firmer. The apparatus was reapplied, and, in order to 
keep up as much pressure as the patient was able to bear, a 
tourniquet was placed over the point of fracture. On the 
31st October the limb was found to be less deformed from 
absorption of a portion of the large mass of callus which 
surrounded the seat of injury, and quite solid. 

By means of a tourniquet over the splints an equable degree 
of pressure can be kept up ; and if pain or other unpleasant 
symptom follow, its application may be removed without 
putting the surgeon to inconvenience. 1 

5th. Electricity has been employed with good effect by Mr. 
Birch, of London. One of the pupils of this gentleman 
informed Dr. Stevens, of New York, that he had seen two 
cases in which it produced the most happy effect. One of 
these cases was seated in the leg, and was of thirteen months' 
standing. "Shocks of electric fluid were daily passed 
through the space between the ends of the bones, both in the 
direction of the length of the limb and that of its thickness. 
The man, being somewhat weak, used bark and porter at the 
same time. The leg was retained in the ordinary fracture- 

1 Amer. Journ. Med. Sci., vol. xxv. p. 273, 1839. 



66 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



dressing. Improvement was very perceptible in two weeks, 
and in six weeks he left the hospital cared." 1 Two cases, 
however, have been reported by Dr. Mott, 2 in which ''very 
powerful shocks of electricity were passed in different direc- 
tions through the part" without benefit. 

6th. Salivation. — This method of cure for disunited frac- 
tures was employed successfully in 1830, by Sir Stephen 
Hammick. Speaking of the cure of these fractures, this 
author says, "Mercury will frequently be required by patients 
who never had any syphilitic taint, not only to act as an 
alterative, but even it will be necessary to push it to a con- 
siderable extent before union of a fractured bone will take 
place." 3 Mr. Colles, of Dublin, has also seen cures take place 
in these cases, by the administration of mercury; and in an 
instance that he witnessed at Guy's Hospital, in 1836, under 
Mr. B. Cooper, which had proved rebellious to other modes 
of treatment (seton, frictions, and the immovable apparatus), 
he suggested its trial to that gentleman. 4 The patient was a 
healthy female, aet. 28, and the fracture, which was at the 
humerus near its middle, was of six months' standing. Four 
weeks after the removal of the seton, salivation was produced 
by the administration of four grains of hydrargyrum cum 
creta, three times a day, and at the same time a leathern girth 
was firmly applied over the seat of fracture. The girth was 
removed at the end of a month, and a perfect cure was found 
to have taken place. In this instance, we are disposed to 
attribute the cure as much to the pressure over the seat of 
fracturemade by the leathern band, as to the administration 
of mercury; and this view of the case we are the more in- 
clined to adopt, as we find that three months after cure, she 
re-entered the hospital, with a fracture of the same arm below 
the part at which it was first broken, which, by the application 
of the same girth, was cured in the usual period. In the 
Cyclopaedia of Practical Surgery (art. Fracture), a case treated 



1 Transl. of Boyer by Stevens — note. 

2 Med. and Surg. Reg., part 2, i. p. 375. 

8 Lectures on Fracts., Amps., etc. p. 118. 
4 Guy's Hospital Reports, ii. p. 399, 1837. 



OCCUKRENCE OF NON-UNION AFTER FRACTURES. 67 

by mercury is mentioned by Mr. Adams. The patient, aged 
26, had, five months' before, broken the femur near the 
trochanter. He was on the use of blue pill till his mouth 
was made sore; then on sarsaparilla, nitro-muriatic acid, and 
a nourishing diet. A spica bandage was applied around the 
pelvis and upper part of the thigh, and over this a starched 
bandage from the toes to the groin. The bandages were 
renewed two or three times for the purpose of ascertaining 
the state of the parts. Two months after the mouth had 
been made sore, consolidation had manifestly advanced, and 
about three months after his admission the bone was suffi- 
ciently firm to admit of his going into the country. Profes- 
sor Sigmund, of "Vienna, has met with five cases where 
syphilitic patients have sustained fractures while undergoing 
mercurial treatment — the radius twice, the fibula, clavicle, 
and the humerus. Complete union in the usual time occurred 
in all these cases. In none of them was the mercurial treat- 
ment discontinued, nor any change made in the diet. In a 
case at the Middlesex Hospital of London, Mr. Arnott failed 
to effect a cure by mercury, and Mr. Charles Hawkins asserts, 
that he has seen mercury freely administered in three cases 
that had come under his observation, without benefit. 1 

7th. The ajiplication of caustic alkali to the integuments over 
the seat of fracture. — In 1805, Dr. Hartshorne, of this city, 3 suc- 
cessfully employed this practice in a case of ununited fracture 
of the external condyle of the femur of four months' duration, 
and in 1811, he applied the same practice to a disunited hu- 
merus of about five months' standing, with the effect of partially 
relieving the patient ; in this last case the issue was three 
inches long and one wide. A third case occurring in the 
femur, about which he was consulted in 1838, was cured by 
the caustic conjointly with pressure. 3 An eschar three inches 
long by one wide, made on the arm with the caustic potash, 
where the injury was of six months' standing, proved inef- 

1 Lancet, ii. 1839, 1840, p. 382. 

2 Eclectic Repertory, Hi. p. 114, 1813. 

3 American Journ. of Med. Sciences for January, 1841, p. 143. 



68 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



in 'i| 



hi. 



fectual in a case which afterwards came under the care of Dr. 
Hays. 1 The actual cautery has also been employed in these 
cases. As with the application of blisters, and moxa, these 
means are particularly adapted to instances of tardy union, 
and in bones seated superficially, as the tibia and ulna, and 
the condyles of the femur. 

8th. Seton. — Writers generally have asserted that the mode 
of treating false joints with the seton was proposed by Wins- 
low, but a reference to his publication shows the statement to 
be erroneous. 2 He used the seton in a case of necrosis accom- 
panied with a fistulous opening, with a view of hastening the 
exfoliation of the diseased bone. Percy, in 1799, employed 
it with a similar view. The treatment of false joint by the 
seton originated with Dr. Physick in 1802, and the first case 
in which it was used is recorded in the Medical Repository, 
vol. i. The fracture was seated in the humerus, two and a 
half inches above the elbow, and was received on the 11th of 
April, 1801. The fragments passed each other about an 
inch. On the 18th of December, 1802, a seton was passed 
between the fragments of the bone. The pain of the operation 
was moderate, and the inflammation that followed was not 
severe. For the first twelve weeks there was no evident 
abatement of motion, but after this time it became gradually 
more stiff, and by the 4th of May, 1803, it was perfectly firm, 
and the seton was removed. Some time afterwards, Percy of 
France treated a non-united fracture of the femur by the same 
means, which succeeded so well, that in two months after the 
operation the patient was enabled to walk without crutches. 
Brainard opposes the use of the seton in these fractures, having 
found that threads of wool, cotton, and silk, when placed in 
contact with the bones of animals, produce inflammation and 
their absorption. Ollier's 3 experiments showed the same fact, 
but he found that, though the seton, if made to surround the 
bone of an animal, produced absorption in its track, it never- 
theless excited the deposit of bone at a certain distance from 



1 American Journ. of Med. Sciences for January, 1841, p. 141. 

2 Arzeneikundigen Annalen, by I. C. Tode. Kopenk, 17S7, 1st part, p. Qo. 

3 These du Cal., 1854. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 69 

its vicinity. He also, in experimenting upon fractures in 
rabbits, produced a large callus by the use of the seton. thus 
proving the different effects of irritation according to its de- 
gree — where intense, suppuration, and where in a weaker form, 
the formation of an abundant callus. 

9th. Setons near the extremities of the hone. — Sometimes the 
seton cannot be passed between the fractured ends of the bone, 
in consequence of their being surrounded by a large carti- 
laginous or bony mass. In such cases, or where from other 
causes the seton as usually placed has failed, M. Oppenheim 
proposed, in 1828, and advocates the passing of two setons, 
not, as Dr. Physick advises, through the intermediate sub- 
stance, but close to the bone near to the extremity of each 
fragment, and recommends that they should be permitted to 
remain no longer than is sufficient to establish free suppura- 
tion. 1 Two cases are given by him, one of the humerus, in a 
male ast. 30, and the other of the forearm, in a female ast. 44, 
in which this mode of practice was adopted with good results. 
In 1833, Saaurer also passed a seton around the tibia near 
the point of fracture. He made incisions down to the bone 
both internally and externally, and then pushed a seton-needle, 
half an inch broad and somewhat curved, through the internal 
wound. Considerable inflammation and suppuration followed, 
and the seton was removed on the tenth day ; three months 
after the operation the patient was able to resume his field 
labors. 2 The same practice has been recommended by Mr. 
Gulliver, and Mr. Ehynd of Dublin. In either of the above 
methods, where the seton is slow in exciting a sufficient degree 
of action in the parts, it has been recommended to smear the 
cord with stimulating ointments, as the unguentum cantha- 
ridis, or the unguentum oxidi hydrargyri rubri, etc. 

10th. The passing of a ligature around the ligamentous mass 
connecting the fragments, and tightening it daily hy means of a 
screw. — This method has been adopted successfully by Seerig. 3 
Longitudinal incisions, two inches in length, were made on 

1 Oppenheim, op. citat. p. 15. 2 Oppenlieim, op. citat. p. 15. 

3 Troschel de Pseudarthrosi, quoted from Arch. Gen. for Jan. 1839, p. 105. 






70 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



k"i 



each side of the fractured bone, and the fragments separated 
one from the other: a needle in the shape of the letter S, to 
which a ligature was attached, was then passed around the 
substance connecting the ends of the bone and the extremities 
attached to the serre-noeud of Grasfe, which was tightened 
daily until the sixteenth day, when it dropped off. 

11th. The introduction of a wire between the fractured ends of 
the bone. — This may be considered as another modification of 
Dr. Physick's method, and has been practised by Dr. Sorarad, 
of Antwerp, in an ununited fracture of the femur of five 
months' duration. The wire was employed in preference to 
the silk seton of Dr. Physick, as M. Somme judged the 
latter to act only on a small surface of the fragments, while by 
his method all the points of surface of the fragments would 
be irritated, and that successively, so that at no time could the 
irritation become dangerous. The operation is thus described : 
" The left femur was broken obliquely about the middle, and 
the fractured extremities rode over each other, the lower 
inwards, and the upper end outwards. The patient being 
placed on his back and supported, I passed a long trocar and 
canula, at first downwards on the inner side of the upper 
fragment, and made it pierce the skin behind, and a little to 
the outside ; the trocar was then withdrawn, and a silver wire 
passed through the canula and out at the posterior opening. 
The canula was then withdrawn, and being replaced on the 
trocar, they were introduced again above and on the outside 
of the lower fragment, and made to pass out at the same 
opening behind. The trocar having been removed, the other 
end of the wire was passed through the canula so that both 
ends were in contact behind, leaving a loop in front. I then 
made an incision in front, from one orifice to the other made 
by the trocar, and drawing the extremities of the wire through 
the wound, brought the loop between the fractured ends of 
the bone, and approximated the edges of the skin with sticking 
plaster." The limb was kept at rest in a fracture box. At 
each dressing, the wire was drawn down, so as to depress the 
loop more and more into the flesh. No bad symptoms fol- 
lowed. Six weeks after the operation, which was done the 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 71 

12th of August, 1828, the union was distinct, bat the wire 
was not withdrawn till the 2d of October. The apparatus 
was continued to the limb until the middle of November. The 
patient is stated to have recovered without apparent shortening 
of the limb. 1 

12th. Acupuncturation. — Malgaigne, in 1837, attempted the 
cure of a disunited femur, in its lower third, by acupunctura- 
tion ; but although mobile, the fragments were in such close 
contact, that of thirty-six needles introduced at different points, 
he could not succeed in passing a single one between the 
extremities of the bone. 2 The same practice has been followed 
by Lewis on the femur, 3 Wiesel on the forearm, and others, 
with success. 

In 1845, Dieffenbach proposed a method for the cure of un- 
united fractures, by perforation of the ends of the bone, and 
the introduction of ivory pegs. His procedure is as follows : 
The limb being strongly extended, and the skin and soft parts 
made tense where the bones are most superficial, he passed 
down to them a long, narrow knife, about half an inch from 
each fractured extremity. Through this opening a small 
gimlet was introduced, and the bone carefully perforated, and 
into the perforations, ivory pegs slightly thinner than the 
gimlet, well oiled, were strongly wedged in. These were then 
covered by charpie, and splints applied to retain the limb in 
perfect quietude. 4 Several examples of success have been 
furnished by its originator. 

Gurlt, 5 who has collected thirty cases which have been thus 
operated on, states that fifteen were cured, thirteen were fail- 
ures, and in two the result was unknown. The late Dr. 
Brainard, of Chicago, urged the treatment by subcutaneous 
perforation of the bones, though he makes no pretension to 
have been its originator. 6 He thus speaks of it : " In case of 

1 Med.-Chir. Trans., xvi. p. 36, 1830. 

2 Manuel de Med. Operat., p. 251, ed. iii. 

3 Mems. de la Soc. de Cnirurg. , vol. ii. 

4 Amer. Journ. Med. Sci., p. 478, vol. xiv. 1847. 

5 Handbuch der Lehre von den Knockenbriichen, Hamm, 1862, p. 662. 

6 Transact. American Med. Associat., vol. vii. pp. 558, 84, 1854. 



72 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



illHUi 



an oblique fracture, or one with overlapping, the skin is 
pierced by an awl-shaped drill, at such a point as to be carried 
through the ends of the fragments, wound their surfaces, and 
transfix whatever tissue may be placed between them. After 
having penetrated the broken extremities in one direction, 
the drill is withdrawn from the bone, but not from the skin, 
its direction changed, and other perforations are made in the 
same manner. On removing the instrument, collodion is 
placed upon the points of puncture." 

In a communication subsequently made to the Chicago 
Medical Journal for September, 1858, Dr. B. gives the result 
of his experience up to that time. " Of thirteen cases, four 
were of the humerus, four of the femur, three of the tibia, and 
two of the ulna. In the humerus, one was of four months' 
standing, aged 30. Two operations were done at an interval 
often days, and it was cured in one month. A second was of 
eight months' standing, aged 29. Four operations were done 
at intervals of ten days, and failed to effect a cure. Another, 
aged 24, had existed for six months. Five operations were 
performed at intervals of a week, and a cure took place in six 
weeks. The fourth was of five months' duration. He was 
treated for five weeks by six perforations without benefit. 
The seton and afterwards resection were then tried without 
producing union. Of the femur, the first, aged 35, was of five 
months' standing. It was treated by eleven perforations during 
five months, and cured. The second, aged 56, was of four 
months' standing, cured in six weeks after four operations. 
The third, also of four months, in a young man, was cured by 
four perforations. The fourth case, aged 36, was of five 
months' standing, and cured in four weeks by one operation. 

In the tibia, one case was of four months' duration, in a 
man, cured in two weeks by one perforation ; the second was 
cured in five weeks by four perforations ; and the third, aged 
21, of seven months' standing, was cured in four weeks by 
four perforations. 

The first of those in the ulna was in a laborer, and had 
existed for three months. It was cured in twenty-two days 
by two perforations ; and the second, a drunkard aged 35, of 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 73 

eighteen weeks' standing, was cured in four weeks by two 
perforations. 

In none of the above cases did any serious accident occur. 
"In one," he observes, "a small abscess, and in another, a 
subject of bad constitution, some swelling resembling erysip- 
elas, which, however, soon subsided. These were the most 
serious results of about sixty perforations." " My practice at 
present," he adds, " is to commence the treatment by two or 
three perforations of the bone through a simple opening of 
the skin, using an instrument of small size, and repeating this 
every ten days or two weeks, gradually increasing the size of 
the instrument and the extent of the wound of the bone, until 
tenderness and some swelling are induced. I have very uni- 
formly found that, when pain and throbbing are felt in the 
seat of fracture, union has commenced." The procedure ad- 
vised by Dr. Brainard is much the same as that imagined by 
Sir Charles Bell. 1 "In one case," says the latter writer, "I 
thought myself, by observations made on animals, authorized 
to propose that a sharp instrument should be pushed obliquely 
down upon the bone, so as to work upon and penetrate the 
extremities of the bones. By this means I imagined the 
wound made by the passage of the instrument would imme- 
diately heal, and yet the extremities of the bone be so excited 
as to resemble the state of simple fracture more than can pos- 
sibly happen after cutting down upon them and sawing their 
ends." Sir Charles, however, never acted on the suggestion. 

The ends of two or three acupuncture needles, after being 
passed into the ligamentous band of union, may be connected 
with the poles of a galvanic battery, and an electric current 
passed as an irritant. This proceeding is called electro-punc- 
ture. In 1848 Mr. Burnam employed galvanism as an excit- 
ing agent in an ununited fracture of the tibia of fourteen 
weeks' duration with success. 2 Dr. McRuer, of Bangor, Maine, 
resorted to it with a like result in an aged female, in whom 
the bones of the leg had not united at the end of eight weeks ; 3 

1 Operative Surgery, 2d ed. 1814, p. 326. 

2 Lond. Med. Times, 1848. 

3 Trans. Amer. Med. Associat., vol. iii. p. 356, 1850. 
6 






74 CONTRIBUTIONS TO PRACTICAL SURGERY. 

and Dr. F. D. Lente furnishes three cases cured by this means, 
where it was applied three times a week. The needles, it is 
supposed, were passed to the periosteum on either side of the 
fracture. 1 

13th. Scraping or rasping the fractured ends of the hone. — 
This process was well known to the ancients. Avicenna de- 
scribes it, and speaks of a philosopher who died from its effects. 
Guy de Chauliac notices this case mentioned by Avicenna but 
to condemn it and blame the philosopher, who, he says, 
" would have better merited this title by living with a halting 
gait, than by having the callus scraped and dying in great 
torments." 2 John Hunter irritated a false joint seated in the 
humerus with a spatula, after laying it open, with success; 
and Sir B. Brodie, on whose authority the statement is made, 3 
thinks that " in all probability Dr. Physick borrowed his idea 
of irritating these joints by means of setons, from what had 
been done by Mr. Hunter." Mr. White, of Cherry Valley, 
New York, formerly President of the Medical Society of that 
State, also advised scraping of the extremities of the bone so 
as to remove their cartilaginous covering. The same practice 
is recommended by Van der Haar, of Holland. In 1814, M. 
Barthelemy proposed the use of a rasp, in form of a saw, and 
conveyed down to the fragments by means of a canula, to 
scrape the ends of the bone. 4 

The practice of scarifying the ends of the bones in ununited 
fractures, in order to induce the deposit of callus by the sub- 
cutaneous section, was proposed by Mr. Miller in 1844. 5 He 
passes a strong needle obliquely down to the part and moves 
its edge freely about in all directions, so as to cut up the lig- 
amentous bond of union, as well as the dense investment of 
the ends of the bones ; the needle being then withdrawn, and 
the puncture covered by plaster. By this means Mr. M. has 
cured an ununited fracture of the humerus, which had sus- 
tained compound injury about ten months before ; the bones 

1 Trans. Amer. Med. Associate, vol. iv., 1851. 

2 Boyer, iii. p. 106. 3 London Med. Gazette, xiii. p. 56, 1833. 

4 Vallet, quoted from Velpeau, ii. p. 588. 

5 Principles of Surgery, 2d ed. p. 692. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 75 

overlapped and could not be adjusted. On removing the 
splints, five weeks after the puncture, the parts were found 
quite firm. The same procedure has proved successful in two 
cases in the hands of Dr. Sanford of Davenport, Iowa, one of 
which had existed for three years, and the other for more ' 
than one year. 1 Mr. Hunter's method of irritating the ends of 
the bone is stated to have failed in two cases at St. George's 
Hospital, London. 2 

14th. Hot iron. — Heat applied between the fragments was 
successfully made use of by M. Mayor in 1828. 3 He thus 
describes its mode of application : " The canula of a large 
trocar was passed between the two oblique fragments of the 
femur, and left eight hours in place, through which a rounded 
iron was repeatedly passed, it having first been held in boiling 
water. By means of this burn at 100° R. I believed that I 
should be able to inflame the bony surfaces and surrounding 
tissues, and place them in a proper condition to unite." The 
case was one of seven months' duration, in which pressure and 
frictions had been uselessly tried. 

15th. Injections. — The injection of stimulating substances 
has been adopted in cases of disunited fractures, accompanied 
by a wound or fistulous opening, by Dr. Hulse, of the TJ. S. 
Navy. 4 In the case reported by him, port wine and water, 
salt and water, and a solution of sulphate of copper were suc- 
cessfully employed, and a cure effected in two months. A 
solution of nitrate of silver, dilute alcohol, wine, and hot water, 
have also been proposed as injections into these joints. The 
rapidity with which a solution of iodine is absorbed, together 
with its well-tested stimulating effects as an injection in hy- 
drocele, would induce me to give a preference to it over other 
stimulating articles. I am not aware of injections having ever 
been made use of in false joint unconnected with wound, and, 
though they might easily be introduced in such cases by 
means of a trocar, yet, judging from the severe effects some- 
times known to follow the injection of stimulating fluid into 

1 Trans. Amer. Med. Associat., vol. iii. p. 356, 1850. 

2 Works by Palmer, i. 505, 1835. 3 Deligation Chirurgicale. 
American Journ. of the Med. Sciences, xiii. 1834. 



76 



CONTRIBUTIONS TO PRACTICAL SURGERY. 






the cellular tissue in cases of hydrocele, I should regard their 
employment as hazardous. 

16th. Resection of the extremities of the hone. — The method of 
treatment by resection was first brought into notice by Mr. 
"White, of Manchester, in 1760. Petit, however, before this 
period removed with a trephine the ends of a fractured bone, 
affected with caries, and the operation is said to have been 
described as long ago as the time of Avicenna. 1 The case in 
which this practice was first tried by Mr. White, 2 was that of 
a boy, aged nine years, in whom a pseudarthrosis existed at 
the humerus of six months' standing. His injury had been a 
simple oblique fracture : the ends of the bone were found to 
be riding over each other, and the arm was not only useless, 
but a burden to him. Amputation was proposed for his relief, 
to which Mr. White objected, and suggested resection of the 
extremities of the bone and afterwards treating the case as a 
compound fracture. The patient did not lose above a spoonful 
of blood in the operation. In about six weeks after it, the 
callus began to form, and soon after became quite firm. 

17th. Resection of one of the fragments only, has been prac- 
tised in two instances by M. Dupuytren with success. This 
procedure, however, did not, as has been said, originate with 
him, since we find a case recorded by one of his own country- 
men 3 in which resection of an inch of the inferior end of a 
non-consolidated fracture of the femur was made in 1758, with 
a view to procure union of the fragments. The same practice 
was pursued by Mr. Fisher at the Salisbury Infirmary in 
1803. The patient, aged twelve, nine weeks previously had 
met with a compound fracture of the upper part of the femur. 
At this date, when first seen by his surgeon, no union had 
taken place. The wound was enlarged, and two splinters of 
bone, one of two and the other of three inches in length, 
were removed. The end of the inferior fragment, which was 
found very jagged, and riding over the superior portion, was 
then exposed, and three inches of it removed by a saw. The 



1 Dictionnaire de Medecine, xiii. p. 503, 2d ed. 

2 Cases in Surgery. 

3 Memoires de l'Acad. Roy. de Chirurgie, iv. p. 113, 8yo. Paris, 1819. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 77 

wound, which previous to the operation had presented an 
unhealthy appearance, was afterwards dressed with lint dipped 
in a decoction of bark, and rapidly healed. In less than two 
months consolidation was perfect, and the boy walking about 
on a crutch, his limb of course being considerably shortened. 1 
White also, in a case situated in the tibia, and Inglis on the 
same bone, employed excision of the superior fragments only, 
with success, long before the time of Dupuytren. In the 
cases both of White and Dupuytren, it was the difficulty or 
impossibility of making the resection of the second fragment, 
which was the cause of limiting it to one. 

Mr. Jordan, of Manchester, in 1855, proposed a mode of 
treatment, which he calls periosteal autoplasty. It consists 
in separating carefully the periosteum from the portions of 
bones to be removed, by means of some blunt instrument, 
and then, after resection of both ends, replacing the separated 
periosteum in such a way as to cover over completely the 
ends of the bones with the raised membrane, and securing 
it by means of suture. Three cases are cited by him in which 
this procedure was employed; one in the leg, a child, and two 
in the humerus, the first of which was cured. 2 

Oilier suggested that in the sub-periosteal resection it is 
important to suture the resected portions of the bones them- 
selves, but thinks no advantage is to be had from that of the 
periosteum, and Dr. H. J. Bigelow, of Boston, has put in 
practice and recommends this latter plan. His method consists 
in detaching carefully the periosteum from the extremities of 
the bone and the healthy shaft for at least a quarter of an 
inch on either side, taking care not to strip the bone higher 
than the line of proposed section or to detach it from the 
muscles, and then, after resection, boring each extremity "at 
a little more than half an inch from its end and through one 
wall only," and wiring the extremities. Dr. B. has adopted 
this practice in nine cases on the humerus, and one each of 
the femur and radius, and all with success except one on the 

! Lond. Med. and Phy. Journ., vol. ii. p. 37, 1804. 

2 Traitement des Pseudarthroses pari' Autoplastic Periostique. Paris, 1860. 



78 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



arm, where amputation became necessary. In five of these 
eases, the seton, drilling, and excision, either with or without 
wiring, had been previously tried and failed. 1 After a detail 
of his cases, Dr. Bigelow remarks, u through not a trivial 
operation, it is not dangerous. 7 ' This conclusion, despite his 
own remarkable success, is not justified. General experience, 
as will be shown hereafter in this paper, proves, that resec- 
tions are dangerous and often fatal. That it is not lightly to 
be undertaken is well shown by one of his cases (V.) where 
"the ends of the bone were turned out with great difficulty/' 
and " the operation occupied about two hours." In Mr. 
Jordan's reflections upon his cases, he observes, the method is 
" not exempt from danger," and thinks no prudent surgeon 
will resort to any resection without having first tried more 
simple means. 

18th. Excising the ends of the bone, and afterwards engaging 
the point of one of the fragments in the medullary canal of the 
other, so as to maintain the extremities in contact, has been 
done by M. Koux. 2 ISTo accident followed the operation, but 
it is stated that at the end of two months a fall upon the frac- 
tured arm prevented any benefit from the treatment, and 
necessitated the amputation of the limb. 

19th. Exposing the ends of the hone and rubbing them over 
with caustic. — The proposal to apply caustics to the fractured 
extremities originated with Mr. White, of Manchester. The 
case in which he adopted it was an ununited fracture of the 
leg of nine months' standing, and in it the extremities of the 
bone were sawn off, and, about a week after, the ends were 
touched with the butter of antimony. A slight exfoliation 
occurred, and the patient recovered with a firm limb. Mr. 
Henry Cline, of London, in 1815, was, I believe, the first who 
made use of caustic, without having recourse to previous re- 
moval of the ends of the bone. His case was successful. Mr. 
Earle, in 1821, made use of it in two instances, 3 though with- 
out success : one of these was in a case of ten months' duration 
in which the seton had previously failed. After the applica- 



1 Ununited Fracture successfully treated, with Kemarks. Boston, 1867. 

2 Berard, These, p. 53. 3 Med. Chir. Trans., xii. 1822. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 79 

tion of the caustic, callus was deposited, and the limb became 
much stronger, but this was afterwards absorbed. The frac- 
ture in his second case (produced by the lifting of a teapot), 
was of nine years' standing, and occurred in a patient "worn 
out with mercury," in whom nearly every cylindrical bone 
in the body was diseased: a case evidently unfitted for any 
operation. In 1827, Dr. Hewson applied the caustic potash 
to an old fracture of the leg, after removal of the ligament- 
ous matter connecting the fragments, with the happiest effect. 1 
At the end of eight weeks cicatrization of the wound had 
taken place, and after twelve weeks the fragments were 
firmly consolidated. Another ununited fracture of the tibia, 
successfully treated by the butter of antimony, has been re- 
ported by Lehmann. 2 The caustic in his case was applied 
after removal of the matter separating the ends of the bone; 
four weeks afterwards some small pieces of bone were dis- 
charged, and in a short time the patient was able to make 
use of his limb. The same caustic has been used with good 
effect in an instance reported by Weilinger. 3 Ollenroth 
touched the fractured extremities with fuming nitric acid, and 
was successful. 4 The caustic potash has been successfully used 
in three or four cases by the late Dr. J. R. Barton, of this city, 
in one of which (following a compound fracture of the leg 
of 16 or 18 months' standing) Dr. Physick discouraged the 
employment of the seton from fear of its failure. I have 
myself, in a case of want of union in the humerus of four 
years' duration, employed the potash with the most perfect 
success. 5 • 

20th. Actual cautery. — Petit describes the case of a youth 
affected with ulcer and caries of the tibia at its middle, which 
became the seat of fracture, the fibula remaining whole, in 
which he cauterized the extremities of the bone, and after- 

1 North American Med. and Surg. Journ. for January, 1828, p. 11. 

2 Graefe & Walther, iii. 2 e call. 1822, quoted from Berard. 

3 Oppenheim, op. citat., p. 8. 4 Oppenhehn, op. citat., p. 7. 

5 Norris, Surgical Report of Pennsylvania Hospital, Am. Journ. of Med. 
Sci., vol. xxxiii. 1838. 



80 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



wards took off the carious parts with a trepan ; having done 
this, he applied lint to the naked bone, well saturated with 
tinct. aloes : at the end of fifty days the diseased bone sepa- 
rated from the sound portion, after which union occurred. 1 

21st. Removing the extremities of the hone and connecting the 
fragments by means of wire. — The tying together of the frag- 
ments in recent fractures of the lower jaw, where there is a 
difficulty of retaining the ends in contact, by means of a 
silver or other wire passed around the teeth, has been recom- 
mended since the days of Hippocrates. In 1818, M. Dupuy- 
tren practised this method upon a case of an ununited fracture 
of the lower jaw, which had existed nearly three years. 2 In 
this instance, he resected the posterior fragment, rasped the 
anterior, and secured the fragments in close apposition by 
means of a platina wire passed around the teeth. The appli- 
cation of this procedure to fractures of long standing, how- 
ever, did not originate with him ; the same practice having 
been pursued in 1805 by M. Horeau in a similar case. 3 The 
idea of securing the long bones in close contact by connecting 
them with wires, in cases of recent compound fractures, was 
also proposed and practised before the time of Horeau, by a 
surgeon named Icart. His method was to surround and draw 
closely together the fragments by means of a metallic ligature, 
fo,r the purpose of preventing displacement ; and states that 
he has seen it put in execution with success. 4 The practice, 
however, was strongly reprobated by his brother practitioners, 
particularly by Pujol, in the journal above quoted, as well as 
in a memoir upon the subject published about the same 
period. For an ununited fracture of the patella it was pro- 
posed, as far back as the time of M. A. Severinus, to freshen the 
ends of the bone, and afterwards tie them tightly one against 
the other, 5 and a late well-known surgeon of a sister city, 



1 Quoted from Heister's Surgery, ed. 1743, p. 114. 

2 Lecons Orales, iv. p. 669. 

3 Journ. de Med. Cliir. and Pharm. in 40 vols., x. p. 195, 1805. 

1 Journ. de Med. Chirurg. and Pharm, par M. A. Roux, xlv. p. 167, 
1776. 
* Velpeau, op. citat., ii. p. 591. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 81 

Dr. J. Kearney Eodgers, has recently revived this practice, 1 
and has in several instances drilled holes through the extre- 
mities of the bone, and then brought them together by means 
of silver wire. The object of the wire is to bring the frac- 
tured fragments in contact, and so retain them. We cannot 
conceive it possible that it should ever be found a difficult 
matter to bring the fractured fragments in apposition after 
resection of their ends. The loss of bone has been, in those 
instances we have witnessed, and must, we judge, always be, 
sufficient to allow of their being so placed by position and a 
proper apparatus alone. The drilling of holes, and fixing of 
wires to the bones, besides lengthening an operation which is 
always tedious and painful, must necessarily expose them to 
denudation of the periosteum, and consequent caries or 
necrosis. We have never had an opportunity of witnessing 
this operation, but all theoretical reasoning would lead us to 
condemn it. One instance has come to our knowledge in 
which the operation of Severinus (on the patella) was put in 
execution, and a fatal result followed on the fourth day. 
Malgaigne, writing in 1840, erroneously gives the credit of 
this mode of operating to M. Flaubert of Eouen, who, he 
says, had performed it on the humerus a short time previously 
with a satisfactory result. 2 

22d. Amputation. — In ununited fractures, as in all other 
cases coming under the care of the surgeon, amputation is his 
last resource ; it should never be resorted to in pseudarthrosis, 
except after the failure of every other means, and then only 
when it renders the life of the patient miserable, and he him- 
self demands it. A few surgeons would have us reject all 
operative measures for the cure of ununited fractures. Among 
these is Larrey, who advises if union has not been effected 
during the first period of treating a fracture that " the case 
should be abandoned to nature." My late friend, Dr. John 
Watson, of New York, entertained nearly similar views, for, 
after having been an attentive observer of the cases of fracture 

1 New York Joura. of Med. and Surg., i. p. 343, 1839— paper by Heard. 

2 Op. citat. p. 249, 3d ed. 



82 CONTRIBUTIONS TO PRACTICAL SURGERY. 

at the hospital of that city for many years, and witnessed 
various modes of treatment instituted for the cure of false 
joints, he avers, " that he has yet to see the case in which he 
would employ either seton, excision, caustic, perforating plug, 
or the wire ligature." 1 Where in the judgment of the surgeon 
it is not thought proper to resort to any of the means of treat- 
ment which have been considered, or where these may alto- 
gether or in part have failed, various machines have been 
devised to palliate the condition of the patient, and render the 
limb in some degree useful. Allusion has already been made 
to those employed by White, Inglis, Kuhnholtz, Troschel, 
Smith, and others, and a reference to the cases of these gentle- 
men will give ample information in regard to this subject. 
With these instruments, as with all the rest of the armamen- 
tarium of the surgeon, the simplest will be found the most 
effectual, and will at the same time be worn with the most 
comfort and convenience. 

Before closing this part of our subject, a recommendation 
promulgated by a surgeon who has devoted much time to an 
experimental essay upon the causes and treatment of ununited 
fractures, merits notice, inasmuch as the practice, in the opinion 
of the writer of this paper, may lead to injury. Dr. Brainard, 
in his Essay, 2 after showing the results which followed the 
operation advocated by him for the cure of ununited fractures, 
viz., perforation of the ends of the fragments, says : " The 
application of the perforator is so little painful, and so effectual, 
that I would recommend its employment where union is at 
all delayed for the purpose of preventing a false articulation 
from being formed, as well as for curing it where it has already 
occurred;" and again, " If there is not decided commencement 
of union at the end of six weeks, perforations should be made 
with a small instrument," and appends in illustration some 
cases treated in this manner which were " not of long standing, 
and might have eventually united without any. operation." 
The instances adduced to support this recommendation all did 

» New York Med. Times, p. 12, 1851. 

2 Transact, of the Amer. Med. Associat., vol. vii. p. 580, Philada. 1854. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 83 

well, but we have no right to assume, nor, as shown by the 
quotation just made, does the author himself do so, that such 
would not have been the result without artificial aid of any 
sort. We know, however, that fever, erysipelas, and abscess 
not unfrequently arise from an operation as simple as that of 
acupuncturation, and experience teaches that these states may 
give rise to an absorption instead of a deposit of callus, and 
that a prolonged treatment, suffering, and complete want of 
union may follow as a consequence. My own observation, after 
a long hospital experience in fractures, leads me to recommend, 
when motion is still found to exist at the period usual for 
these accidents to become consolidated — that is, in cases of 
simply delayed union, that the treatment by perfect rest and 
pressure should be continued, and if possible more carefully 
attended to than before, for, as a general rule, cases in which 
there is this delay in consolidation are not to be despaired of 
even after the lapse of five or six months. Constitutional 
treatment should at the same time be carefully employed, 
every means being taken to invigorate the patient, and to 
place his general health in a good condition. If, after the 
lapse of the time mentioned, firm union still fails to occur, 
the case should on no account be abandoned by the practi- 
tioner, but frictions, irritants, and electricity should be used, 
and not until these have been first fairly tried should resort to 
operative means be recommended, and even then I would long 
hesitate in urging them, in cases which incommode the patient 
but slightly, or which can be efficiently remedied by artificial 
support; but under opposite circumstances, severe and dan- 
gerous as the mildest of them must be acknowledged at times 
to be, sound surgery and experience justify their use. 

The few pages devoted to the consideration of non-con- 
consolidated fractures in our treatises on surgery, are for the 
most part extremely vague and unsatisfactory ; and in practice 
the various modes of treatment recommended for their cure 
are resorted to without discrimination, according to the par- 
ticular fancy of the surgeon. The methods that we have 
enumerated have all at different times been much vaunted by 



84 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



practitioners, and, as might be expected, have all in some in- 
stances been followed by failure. One of the British writers, 
who appears to have devoted most attention to the subject of 
these affections, is of opinion that all modes of treatment have 
been very unsuccessful ; so much so, that he thinks he is far 
within the mark in stating, that not one in twenty in which 
they are tried is followed by a favorable result. This state- 
ment is based upon recollection alone; though not very un- 
frequent, the failures are believed not to be so numerous as 
is here stated. Our tables show, that out of 150 published 
cases, 113 have been cured. In their treatment no exclusive 
method should be adopted; all may at times be applicable, 
and may be regarded as good or bad, according to the par- 
ticular condition of the parts in each individual case. In 
making choice of a plan of treatment, we should be governed 
by the situation of the injury — whether near a joint or other- 
wise — the limb affected — the length of time which the fracture 
has existed — the degree of mobility existing in the fragments 
— whether the fragments be in apposition or otherwise — 
whether connected by a ligamentous band, or united by means 
of a preternatural capsule, should be carefully ascertained 
before the kind of operation to be employed is decided upon. 
The five following classes will embrace all the modes of cure 
most commonly resorted to ; and the particular cases to which 
these are applicable, together with the main objections which 
at different times have been urged against them, we shall now 
briefly enumerate. 

1. Compression and rest. 2. Frictions. 3. Seton. 4. The 
application of caustic to the seat of fracture. 5. Eesection 
of the ends of the bones. 

1. Compression and rest. — Commonly speaking, the terms 
ununited, or disunited, when applied to fractures, are used 
simply to express that the bones bend and have not become 
firm at the injured part, without reference to the length of 
time that has elapsed since the occurrence of the accident, or 
the state of the fragments which exist ; and many cases are 
reported which were cured by continuing the application of 
the apparatus employed, without requiring any further assis- 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 85 

tance from the surgeon. Properly speaking, the union in 
these cases is simply delayed ; and it is to these delayed con- 
solidations that the treatment by rest and compression is pecu- 
liarly applicable. Besides these, compression and rest are 
always adapted to, and will be likely to prove successful in, 
cases of non-union in which the cause can be attributed to 
motion, or want of proper position after the recent fracture, 
where the ends of the bones are not absorbed and are con- 
nected by fibro-cartilaginous substance, into which sufficient 
bone has not been deposited, or to cases where no sort of union 
has taken place in consequence of previous want of perfect 
apposition, provided the ends can be brought into contact and 
the fracture has existed but a few months. To cases, also, which 
are accompanied by an inflammatory state of the fragments of 
the fractured limb, this treatment is well suited. In all of the 
first-mentioned order, it must be evident that the chances of 
union become probable when the broken bones are brought 
into contact and so retained ; and in the latter, consolidation 
will be apt to occur upon the subsidence of the increased 
action in. the limb, consequent upon its being placed in a state 
of perfect quietude. As the method is unattended with danger, 
it should alwavs be resorted to in instances of the kind men- 
tioned, particularly when in young subjects, previous to per- 
forming any of the more serious operations which have been 
proposed for remedying this accident. In cases where there 
exists an approach to a capsular ligament, or where the ends of 
the bone are diseased, or are prevented from uniting by the 
interposition of a foreign substance, or are rounded and sepa- 
rated, though connected by means of ligamentous matter, the 
mere influence of pressure and rest is not alone sufficient to 
produce a cure. Where pressure directly over the seat of 
fracture is made use of, the tourniquet is preferable to the 
roller, as by means of the screw a more equable degree of 
pressure can be kept up, and, if pain or other unpleasant 
symptom follow its application, can be loosened without 
putting the surgeon to inconvenience. Pressure and a state 
of perfect repose have been sometimes produced by the im- 






86 CONTRIBUTIONS TO PRACTICAL SURGERY. 

movable apparatus, which, if ever to be approved, is in the 
class of injuries that we are now treating of. 

Out of 36 cases included in our table, treated by pressure 
and rest, 29 were cured. Of these, 

13 were in the femur, of which 9 were cured. 

7 " leg, " 7 

12 " humerus, " 9 " 

4 " forearm, " 4 " 

The longest period that the fracture had existed in these 
cases was 22 months (femur, ast. 27). The shortest period was 
4 weeks (forearm, set. 12). The average period was 5 months 
and 12 days. The longest period required for a cure was 5 
months (humerus, get. 24). The shortest period was 18 days 
(femur, set. 25). The average period was 9 weeks. 

In the 36 cases in which pressure and rest were employed, 
accidents depended upon the treatment, and, not terminating 
in death, are stated to have occurred four times — -(excoriations 
1, severe pain and inflammation 3). 

2. Frictions. — In making use of frictions, the object aimed 
at is to break up any ligamentous bands that may unite the 
fragments of the bone, and by rubbing these together destroy 
any covering which they may have, and produce a degree of 
irritation as great as would follow a recent fracture. Boyer 
denounces the use of frictions, believing that if deposition of 
callus has commenced, rest alone will be sufficient for the 
cure, and, if a false joint is already established, the frictions 
will be totally without benefit, and will, besides, expose the 
patient to serious accidents from the contusion and tearing of 
the surrounding soft parts. 1 Before the time of Boyer, Duver- 
ney had pronounced this method to be only good in the study, 
" for, however the whole end of the cemented bone be rubbed, 
it is useless and even dangerous to the patient." 2 Kluge per- 
mits his patients to use a limb if it still remains flexible after 
the lapse of time usually occupied in consolidation, and, when 
inflammation is thus excited, he restores it to its previous 

1 Op. citat., iii. p. 106. 

2 Diseases of the Bones, transl. by Ingham, p. 176. 



OCCURRENCE OF NON-UNION AFTER FRACTURES.. 87 

quiescent state. 1 In every instance a quick and firm consoli- 
dation resulted. A good example of the benefit to be derived 
from frictions produced by allowing the patient to move about 
upon his limb is given by Mr. Home. 2 

Experience proves that where there is simply tardiness in 
the formation of callus, the method by friction, though it has 
often failed, may be serviceable ; and, as, with the exception 
of the case reported by White, in which abscess followed, we 
are not aware of any instance ever having been reported in 
which unpleasant symptoms were produced by it, would advise 
a trial being made with it after compression has failed, before 
resort is had to any more severe measure. Frictions, how- 
ever, in such a degree as to risk serious injury to the surround- 
ing parts, are unwarrantable, nor should they ever be emploj^ed 
where any degree of union has commenced, until it is well 
ascertained that nature unassisted is incompetent to produce 
firm union, as we know that motion will sometimes cause 
rapid absorption of the matter effused between the ends of the 
bone. On this account the practice advised by some surgeons, 
w r here union is tardy, of removing all apparatus and allowing 
the patient to move his limb freely while in bed, is to be de- 
precated as being doubtful in its results. 

The treatment by frictions is particularly applicable to the 
cases described in our second order, where the fracture has 
been nearly transverse and union of no sort exists between 
the fragments. In most instances of our third order, the fibro- 
ligamentous connections between the fragments is so strong as 
to prevent a fair trial of this means ; but such cases would 
probably all be cured by rest and compression. Of the two 
methods of making use of frictions, preference should, we 
think, be given to that of seizing the extremities of the bone 
and rubbing their ends together, as by it frictions are more 
effectual, and the liability to danger less imminent, than in 
binding up the limb and suffering the patient to move about 
upon it. Where, however, the degree of motion is slight, the 

1 Oppenheim, op. citat., p. 4. 

2 Trans. Soc. for Improve, of Med. and Chir. Knowledge, vol. i. 1793. 



88 



CONTRIBUTIONS TO PRACTICAL SURQERY. 



latter mode may be advantageously emplc^ed. The necessity 
of a state of perfect rest, after a sufficient degree of irritation 
has been once set up, has been already stated, and is highly 
important. 

In addition to the cases cited in the accompanying tables in 
which frictions have been used, the method has been em- 
ployed successfully by Briot; 1 by Champion, 2 in a leg after 
two and a half months; Jacquier d'Brvy, 3 in a leg; Vo- 
gel, 4 in a clavicle; Basedow, 5 in a leg after five weeks; 
Steinheim, 6 in a femur; Sanson, 7 in a femur of more than a 
year's duration ; by Ashmead (communicated to author), in 
two cases in the leg after the lapse of several months ; and by 
Kirkbride, in a humerus that had failed to unite at the end of 
three months. 8 Bonn, Germain, Haiti, Ansiaux, and others 
have, however, failed. 

3. Seton. — From its first proposal by Dr. Physick, the use 
of the seton has received continued opposition, both in Eng- 
land and France. By authoritative writers of these countries, 
it is stated most generally to have failed in producing union. 
Mr. Amesbury, writing in 1829, thus expresses himself in re- 
gard to it : "I have seen three cases of non-union treated with 
setons — one in the femur and two in the humerus. The con- 
stitutional disturbance produced by the seton in the thigh was 
extremely severe : but the irritative fever occasioned by it in 
the other two instances was not great. Not the least benefit 
was obtained from its employment in either case." He adds 
" Though I have heard of many cases of non-union treated by 
the employment of setons, I am not aware that there are more 
than three treated in this country, where its operation appears 
to have brought about consolidation of the bone." 9 Another 
high authority, Mr. Lawrence, remarks: 10 "I believe it may be 
said that there are some two or three instances recorded, in 



i Malgaigne, p. 248. 2 Velpeau, op. citat., ii. p. 783. 

3 Idem. 4 Idem. 

5 Berard, op. citat., p. 44. 6 Oppenheim, op. citat., p. 5. 

' Diet, de Med. and Chir. Prat., iii. p. 500. 

8 Am. Journ. of the Med. Sci., xv. 1835. 

8 Op. citat., p. 224. >° Lond. Med. Gazette, vi. p. 355, 1830. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 89 

which, after some weeks or months of confinement, with a good 
deal of pain and danger, the union has been effected in this 
way ; but in other cases the introduction of the seton has 
failed." Speaking of the seton in his lectures, in 1833, Brodie 
mentions his having used it in three cases. The first was in 
an ununited fracture of the femur, and union took place though 
it was not completed until after a long period of time. The 
second case, also of the femur, was followed by so much dis- 
turbance of the constitution, that he became alarmed, and the 
seton was removed. The symptoms after this subsided, and it 
was re-introduced and kept in for a length of time, but no 
cure was effected, and the patient left the hospital with the 
bones as loose as when he was first admitted. In the third 
case the injury was in the clavicle, and was of many years' 
standing, and here a perfect cure was accomplished after the 
use of the seton for several weeks. He then adds, " The result 
of the practice in England appears to be, that sometimes it 
has succeeded in the upper extremities, but that where it has 
been performed on the lower extremities, as far as I know, it 
has only succeeded in a single instance, viz., that of the 
patient under my care." 1 Mr. Palmer, 2 writing in 1835, speaks 
of its having succeeded " in a few cases." Syme thinks the 
irritation determined by the presence of a seton cannot be 
useful but when there is a commencement of union. a M. 
Sanson summarily condemns the treatment with the seton, and 
advises its rejection. 4 Larrey says he would never recommend 
the seton or resection, in these cases ; 5 and M. Velpeau 6 de- 
scribes it as a very uncertain method of treatment, and gives a 
preference to the operation of resection, if frictions, or the 
immovable apparatus, are not sufficient for the cure. The 
opinions expressed by the above quoted gentlemen show the 
estimation in which the method is held by many in Europe. 
Most erroneous notions of the estimation in which the seton 
continued to be held after an experience of many years, by 

1 Lond. Med. Gazette, xiii. 2 Edit, of Hunter, i. p. 505, 1835, note. 

3 Edin. Med. and Surg. Journ., July, 1835. 

* Diet, de Med. and Chir. Prat., iii. p. 504. 

5 Clin. Chirurg., iii. p. 460. 6 Op. citat., ii. p. 587. 

7 












90 CONTRIBUTIONS TO PRACTICAL SURGERY. 

its discoverer, as well as of the opinions entertained of it by 
the great mass of surgeons in this country, are at this time 
circulated abroad. In some editorial remarks of one of the 
French journals, 1 it is gravely asserted that in the United 
States so little benefit has been derived from the employment 
of the seton in false joints, that it is now no longer employed 
there — Dr. Physick himself having renounced the treatment 
during the latter years of his life. "We have authority for 
stating that up to the period of his death, Dr. Physick always 
advocated the treatment of these cases by the seton, and may 
safely assert, that results in America have proved it one of the 
safest, least painful, and most effectual, of the numerous ope- 
rations that are performed for the cure of pseudarthrosis. 

The following instance, taken from the Case Book of the 
Pennsylvania Hospital, 2 is interesting, as showing that Dr. 
Physick was not prevented from resorting to the seton even 
after an accident had occurred on a first attempt at placing it. 
On the 20th November, 1807, Bryan Malone, aged thirty, 
received a fracture of the right leg, a little below its middle, 
and also a fracture of the thigh of the opposite side. The 
thigh united in the usual time, while in the leg the fibula 
united but the tibia remained loose. At the end of a year a 
seton was introduced between the ununited fragments and a 
large bloodvessel wounded. Hemorrhage was with difficulty 
restrained by firm compression, elevation, cold, etc. The 
seton was withdrawn during the treatment for the bleeding, 
and no union had taken place after the ulcers resulting from 
the wound had healed. In March, 1809, the patient entered 
the hospital, and on the 24th of that month, Dr. Physick 
passed a seton; some fever and pain followed it. On the 18th 
of June the fracture was firmly united and the seton was 
removed, and he left the hospital on the 29th. Another in- 
stance in which a second seton was used successfully, after a 
previous attempt by this mode of treatment had failed, is given 
by Koux. 3 

1 Gazette des Hopitaux, No. xlix. p. 196, 1839. 

2 Vol. i. p. 88. 3 Gaz. Med., No. 26, p. 407, 1842. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 91 

Much difference of opinion prevails, not only as to the mode 
of applying the seton, but also as to the length of time which 
it is necessary to allow it to remain in place. Dr. Physick 
recommends it to be passed through the integuments and 
between the ends of the bone, by means of a long seton needle 
armed with a silk ribbon, or French tape, without previously 
cutting down to the bone, and advised that it should be left 
in place for four or five months, or longer. 1 Other practi- 
tioners, however, have preferred that the soft parts should be 
first divided, so as to expose the seat of the fracture, and that 
it should be removed at the end of a week or two. The first 
method of operating, as being less painful, and attended with 
less danger, should, we think, be preferred. The length of 
time the seton should be allowed to remain, it is impossible to 
fix upon, but, as the object of it is to excite action in the bone 
and parts around, and not to promote suppuration, which we 
know in compound fractures often prevents the union, it would 
seem that it should be removed without regard to time, as 
soon as a considerable degree of action is excited, and before 
excessive suppuration is established. After its withdrawal 
the limb should be splinted with great attention, and every 
possible care taken, to keep it in a state of perfect quietude. 
The seton is especially suited to those cases of preternatural 
joints which occur in the upper extremities, inferior maxilla, 
and clavicle, where the fragments can be placed in apposition. 
In the femur it has often failed ; Dr. Physick has tried it in 
three cases of artificial joint in this bone, without satisfactory 
results. The experience of Sir B. Brodie, as we have seen, is 
to the same effect. The cause of failure in these cases is pro- 
bably owing to its inadequacy in the larger bones to excite a 
degree of inflammation sufficient to give rise to ossific action. 
One of the cases in which the seton failed in the hands of Dr. 
Physick, was that of an adult male who was admitted into the 
Pennsylvania Hospital, Feb. 17th, 1810, with an artificial joint 
of the femur following an oblique fracture of the bone just 
below the trochanter major. His accident had happened eight 

1 Hays, in Am. Journ. Med. Sci., Nov. 1830, p. 271. 




92 CONTRIBUTIONS TO PRACTICAL SURGERY. 

months previously. On the 28th an incision down to the bone 
was made over the seat of the fracture, and a seton introduced. 
On the 4th day, fever and retention of urine followed, but 
soon disappeared. On the 20th of April an extensive abscess 
formed in the thigh, and his health had become in some de- 
gree impaired. On the fourth of July, on account of the 
fever, diarrhoea, and debility of the patient, the seton was 
removed, having been allowed to remain four months and 
four days, without producing any bony union. 1 I have myself 
witnessed in our hospital two cases in the femur where the 
seton was tried without benefit. The first of these was in a 
woman, aged 83, who was admitted in February, 1848. The 
accident had happened eight months before admission by being 
thrown from a swing, and the upper end of the bone had pro- 
truded slightly, but the wound healed kindly. The injury 
was near the middle of the bone and no trace of union could 
be detected. Pressure and rest had been used before her 
reception, and were again tried for three months after her ad- 
mission, without benefit. A seton was then introduced on the 
24th of June with no beneficial result, and in October it was 
removed, and soon afterwards I amputated the thigh at her 
urgent request. In the second case, that of a laborer, aged 
23, the injury was of nine months' standing, and three weeks 
after its insertion by Dr. Peace the patient died of pyaemia. 

The situation of the fragments — their being widely sepa- 
rated, or placed in such a direction that they cannot be readily 
kept in contact ; or the abundant deposit of callus about their 
extremities, may be obstacles, sometimes insurmountable, to 
its use. The existence of great malposition in the fragments 
will generally preclude its employment. Close proximity of 
the fracture to the main artery and nerve, or to an important 
joint, may also at times prevent a trial with the seton. Where 
the bone has been for years disunited, and the fracture is very 
loose, or presents irregular surfaces, the seton is entirely un- 
suited. In all other cases, it should be preferred to all other 
operative procedures, as in case of a failure with it some of 

1 Perm. Hosp. Case Book, i. p. 108. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 93 

the more serious operations may always be resorted to. Wein- 
hold 1 imagines that the principal cause of failure with the 
seton (as used in Europe in connection with an external in- 
cision) is, its permitting the access of the external air to the 
extremities of the bone, which, for that reason, are extremely 
disposed to become carious ; and to obviate this he proposes 
making the wound funnel-shaped, and using a conical or wedge- 
like seton. In addition to the cases treated by the seton which 
have been already alluded to, or are included in our tables, 
this method of treatment has been successfully used in the 
forearm by Delpech, 2 in the leg by Rigal de Gaillac, in the 
clavicle by Eandolph, and by Saurer in the leg in a case of 
eight months' duration. 3 Of three ununited fractures of the 
humerus in which the seton was used by Mr. Crompton, 4 two 
were successful after extensive suppuration, and in the third, 
the needle could not be passed between the ends of the bone, 
and, as there was a good deal of strength in the member, 
the patient was advised to allow it to remain as it was. In 
three cases situated in the tibia, treated by the same surgeon, 
all were much benefited by the seton, combined with pressure 
and rest, and he believes they all got well finally. A fourth 
instance which he saw in the tibia, where the fractured ex- 
tremity became loose during a severe attack of pleurisy, was 
also caused by the same means. In the case of a non-united 
fracture of the humerus, cited by Lombard, 5 it was employed 
without benefit, and on the same bone with only partial suc- 
cess, by Beclard of Strasburg. In another case on the humerus 
treated at the Kichmond Hospital with the seton by Mr. Car- 
michael, its introduction was followed by a severe attack of 
erysipelas and very nearly caused the death of the patient. 6 
An ununited fracture of the acromion process of the scapula, 
occurring in a female, which was treated by the seton some 
years back at the almshouse infirmary of this city, termi- 
nated in death. Professor Mott's experience in the use of the 

1 Med. Recorder, xiii. 2 Clin. Chir., i. p. 255. 

3 Oppenheirn, op. citat., p. 15. 4 Lond. Med. Gaz., vol. ii., N. S., 1850. 

5 Velpeau, op. citat., ii. p. 586. 

6 Cyclopaedia of Pract. Surg., p. 91, 1842. 



94 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



seton has been large ; eleven cases have been treated by this 
method by him, of which three were of the femur, three of 
the tibia, and five of the humerus. In all it succeeded per- 
fectly except in three of the last-mentioned bone, which were 
afterwards cured by resection of the ends. 1 

Keference to the tables appended to this paper exhibits the 
following results in 46 cases in which the seton and its modi- 
fications were employed. Of these, — 

13 were in the femur, of which 9 were cured. 
10 " leg, " 10 " 

16 " humerus, " 10 " 

6 " forearm, " 6 " 

1 " jaw, " 1 " 



Of these 46 cases, 21 are stated to have had an incision 
made down to the bone previous to the introduction of the 
seton, and 24 had it passed without a previous incision. Of 
the 21 where previous incision was made, 17 were cured, 2 
improved, 1 failed, and 1 died. Of the 24 in which there was 
no previous division of the soft parts, 18 were cured, 1 
amended, 4 failed, and one died. 

In one case the seton was passed through a fistulous open- 
ing which previously existed. 

The longest period that the fracture had existed in these 
cases was 10 years (femur, set. 26). The shortest period was 
six weeks (tibia, set. 48). The average period was 12 months 
and 12 days. 

The longest period that the seton was allowed to remain 
was 13 months (humerus, aet. 48, failed). The shortest period 
was 7 days (forearm, cure). The average period was 7 weeks 
and 3 days. 

The longest period required for the cure was 8 months 
(femur, ast. 41). The shortest period was 3 weeks (humerus, 
aet. 23). The average period was 2 months and 24 days. In 
17 of the cases in which the seton was employed, other 
methods of operating are stated to have been tried and to 
have failed. 



1 Vache, in Am. Journ. of the Med Sci., ix. p. 262. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 95 

In the 46 cases treated by the seton, accidents dependent 
upon the method emploj'ed, and not terminating in death, 
are noted as having occurred 12 times (arterial hemorrhage 
twice; severe fever, erysipelas, or profuse suppuration, ten 
times). 

4. The application of caustic to the seat of fracture. — The 
application of caustic to the ends of the fractured bone after 
free exposure of them is a more powerful means of effecting 
the requisite irritation in the periosteum and bone than the 
seton, and seems worthy of more extensive employment than 
it has heretofore received. From the ease with which the 
operation can be done, the little pain attendant on it, and the 
almost certainty of producing by it a degree of action in the 
parts sufficient to excite a deposit of callus, without at the 
same time keeping up that action so long as to cause excessive 
suppuration, which often leads to failure, I am induced to 
prefer it to excision of the ends of the bone, and would re- 
commend it in those cases which are rebellious to the simpler 
modes of treatment, viz., compression, frictions, and the seton. 
In performing the operation, the seat of fracture is to be 
fairly exposed, the substance connecting the ends of the bone 
divided, and the wound carefullv dried ; after which the 

7 «• 7 

caustic is to be rubbed over them. The wound should then 
be filled with lint, and the limb placed in a state of the most 
absolute rest. 

The operation with the caustic is as applicable to the lower 
as the upper extremity, and is the only procedure, except 
resection, that is well suited to cases which have been for 
years disunited, or are very movable, and surrounded by a 
preternatural capsule. 

Different caustics have been made use of in these cases. 
White and Lehman employed the butter of antimony. Ollen- 
roth has proposed the nitric acid. In the cases reported b}^ 
Cline, Earle, Barton, and myself, the caustic potash was used, 
and is, I think, preferable. 

5. Resection of the ends of the hone. — This method of treat- 
ment, though it has been frequently adopted with success, is 
nevertheless attended with great danger. All writers who 



. 



., 



;! ! !;M 



96 CONTRIBUTIONS TO PRACTICAL SURGERY. 

have practised it acknowledge its severity, and few recom- 
mend its employment except in extreme cases. Mr. Lawrence 
thus notices resection : " This is a serious proceeding ; indeed, 
in the middle of a fleshy limb, as the thigh for example, it 
must be a very difficult thing to accomplish." 1 Boyer de- 
scribes it as one of the most serious operations in surgery, 
and speaks of it as "painful, bloody, and of uncertain suc- 
cess." 2 Barton views it as difficult for the surgeon, besides 
being painful, and of doubtful result both to the limb and life 
of the patient. 3 Liston regards it as a "difficult and severe 
process;" 4 and states that he has never attempted the opera- 
tion but once, and then failed in procuring union. Somme 
mentions an instance of ununited fracture of the arm, in 
which he witnessed the operation of amputation of the frac- 
tured extremities without any benefit resulting, and pro- 
nounces the method "barbarous," and thinks "it ought to be 
rejected from surgical practice." 5 Gouraud looks upon it as a 
retrograde step in surgery. 6 Mr. Eynd, 7 speaking of sawing 
off the ends of the bone in these cases, says: "I suppose no 
surgeon of the present day would seriously entertain it." A 
recent continental writer 8 well remarks, that "in pseudar- 
throsis of the thigh the question may seriously be asked if 
we should not prefer amputation at the point of the false 
joint to any other dangerous or doubtful operation. This 
question only the peculiarity of the individual case can decide. 
In some cases the safe aid of a suitable splint apparatus is 
preferable to any operation," and M. Yelpeau, though an 
advocate for this mode of treatment, candidly exposes its great 
dangers. We should never, says he., " decide upon this opera- 
tion without having well considered it. Requiring a deep 
and large incision into the soft parts, it places the bone in the 
state of a recent fracture accompained with severe wound, 

1 Lond. Med. Gaz., vi. 1838. 2 Maladies Chirurgicales, iii. 

3 Med. Kec., ix. p. 276, 1826. 4 Lancet, ii. 1835-6, p. 169. 

5 Med. Chir. Trans., xvi. p. 39. 

6 Med. Op. Velpeau, ii. p. 589, Paris, 1839. 
i Dublin Quart. Med. Journ., vol. iv. 1847. 
s Billroth, trans, by Hackley, 1871, p. 210. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 97 

from whence results the danger of excessive suppuration, 
erysipelas, caries, necrosis, as well as of purulent absorptions, 
and phlebitis." 1 Jourdan thinks that resection is only prac- 
ticable on the humerus, or at furthest on the femur, and that 
the accidents which terminate almost always in death should 
make us prefer amputation. 2 Mr. Rowlands, after reporting 
a case in the femur successfully operated on by resection of 
the ends, states, that the operation far surpassed in sev.erity 
"anything I had ever undertaken or witnessed, and I am 
doubtful as to the propriety of recommending it to others." 3 
On the femur this operation is particularly severe, and the 
great length of time required for its performance on that bone 
is alone, in debilitated patients, a sufficiently strong objection 
to it. In a case of resection of the thigh-bone noticed by M. 
Vallet, 4 the operation is stated to have been of extreme sever- 
ity, and to have lasted more than an hour : the patient, who 
was young and vigorous, had convulsions, and died the same 
evening. In the case of "Walb, reported by Dr. Kirkbride, 5 
the operation lasted near two hours, the patient afterwards 
dying of pyaemia on the sixteenth day. And in a patient 
that I saw operated upon at the Pennsylvania Hospital 
in 1833, the operation was tedious and painful, though, after 
a long confinement and exposure to great dangers, he was 
finally cured. In one of the cases reported by Dr. Bigelow 
on the femur, the operation of resection and drilling "occu- 
pied about two hours," and "the ends of the bone were turned 
out with great difficulty." Speaking of the treatment of un- 
united fracture by excising the ends of the bone, Mr. Crosse 
observes, that he has known excision cure; "but it so often 
fails as to render the practice very discouraging," 6 and M. San- 
son thinks that "all prudent practitioners will agree that it is 
better to leave the patient with his infirmity, which in no way 
endangers life, than seek to remove it by an operation which 
greatly perils it." 7 

1 Idem., ii. p. 592. 

2 Diet, des Sc. Med., art. Fausse Articulation. 

3 Med. Chir. Trans., ii. p. 49. * Med. Op. Velpeau, ii. p. 589. 
5 Am. Journ. Med. Sci., xvii. p. 46. 6 Retrospective Address, p. 80. 
7 Diet, de Med. and Chirurg. Prat., iii. p. 505. 




98 CONTRIBUTIONS TO PRACTICAL SURGERY. 

The mode of treatment by resection is more particularly 
applicable to such fractures as are accompanied with great 
deformity, or have been for a very long period disunited, and 
have the ends of the bone very widely separated and loose, 
or such as are surrounded by a preternatural capsular liga- 
ment, with the fractured ends enlarged, than to those cases in 
which the ends of the bone are connected together by a liga- 
mentous band only. It is better adapted to parts in which 
but a single bone exists, as the humerus and femur, than to 
the forearm or leg. As with the seton and other methods 
of treatment, it must necessarily fail where the want of con- 
solidation arises from any constitutional cause. Where the 
preternatural joint is near to an important articulation, it is 
altogether inapplicable. By some writers it has been thought 
to be peculiarly suited to such pseudarthroses as are pro- 
duced by a necrosed state of the extremities of the fragments; 
but in these cases, as a general rule, any very serious ope- 
ration is unjustifiable, experience teaching us that it is better 
to leave the removal of the bone to nature, and in no way 
interfere until the diseased parts are separated by the absorb- 
ents, when they should be removed, and the limb after- 
wards supported as carefully as in cases of recent fracture. 
A cure by resection, it is to be remembered, is always ac- 
compained by more or less shortening of the limb — a slight 
inconvenience for the arm, but a matter which should enter 
into our calculation when the lower limb is the seat of the 
infirmity. 

In performing the operation of resection of the ends of the 
bone, a longitudinal incision is to be made opposite to the 
point of fracture, and, in that part of the limb in which the 
bone is most superficial, care being taken at the same time 
to avoid the neigborhood of large arteries or nerves. The 
surrounding soft parts are then dissected from the extremities 
of the fragments, which are to be successively pushed out and 
removed with a saw, no more of the bone being taken away 
than is absolutely required. The ends of the bone are after- 
wards to be brought in contact, and the limb so placed as to 
favor the discharge of pus from it, care at the time being taken 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 99 

to retain it at perfect rest, and to treat it in every respect as 
a severe compound fracture. 

My own experience, together with a close examination of 
most of the recorded cases of excision of the ends of the bones, 
leads me to regard it, particularly in the femur, as an opera- 
tion of so formidable a nature, both as to the risk incurred by 
the patient and the great amount of suffering that it gives rise 
to, that it should never be resorted to until all other modes of 
treatment have failed, or are from some peculiar circumstances 
inapplicable. 

In addition to the instances which I have noticed elsewhere, 
resection has proved successful in the hands of Josse, 1 Hysern, 2 
Andrews, 3 Dupont, 4 and Langenbeck, 5 on the humerus: with 
Fricke 6 and Holscher 7 on the forearm ; with Dubois, 8 Josse, 9 
Dupuytren, 10 and Diisterburg, 11 in the leg; and with Yiguerie 12 
and Moreau, Jr., 13 upon the femur. 

Mr. Amesbury has seen the operation of removal of the 
ends of the bone twice unsuccessfully performed in the 
humerus. The first was a man of strong constitution, who, 
after many months' confinement, was allowed to get up. He 
saw him eighteen months after the operation, when the 
wound had healed, but the arm was much worse than when it 
was performed. In the second instance, after many months' 
suffering from exfoliation and abscesses, the man left his bed 
with the limb much worse than before. 14 Dupuytren lost a 
patient after this operation on the humerus, and derived no 
benefit from it in another case on the same bone. 15 Mr. James 
has employed it in the arm unsuccessfully. 16 Yiricel lost a 

1 Med. de Ckirurg. Prat., p. 321. « Med. Operat. of Velpeau, 1. 

3 Lond. Med. Journal, 1781, i. 

4 Archives Generates, ii. p. 628, 1823. 5 Cooper's Surg. Diet. 
6 Med. Operat. of Velpeau, ii. p. 590. ' Oppenheim, p. 11. 

8 Velpeau, ii. p. 590. a Mel. de Ckir. Prat., p. 311. 

10 These of Berard, p, 52. 'i Oppenheim, p. 11. 

12 Larrey, Military Surgery, trans, by Hall. 

13 Med. Operat. of Velpeau, ii. p. 590. 

14 Op. citat., p. 216. 15 Q az> Med. 1831. 

16 Retrospective Address— Provin. Med. and Surg. Trans., viii. 1840. 






100 CONTRIBUTIONS TO PRACTICAL SURGERY. 

patient a few days after rasping the fractured extremities. 1 
Mr. Allan knew the operation to fail in the hands of John 
Bell, whom he assisted in a case on the humerus of twelve 
months' standing; 2 and Physick mentions an instance in 
which it was performed unsuccessfully upon the humerus, 
and states that the patient afterwards entered the hospital in 
this city, where the limb was amputated, and related to him 
the great suffering which he had experienced in the operation 
of excision. 3 Eesection has also altogether failed in the 
hands of Ansiaux, 4 Moreau, 5 Beck, 6 and Eoux, 7 on the 
humerus, with Warmuth 8 and myself, 9 on the ulna; and Dr. 
Guntz, of Leipsic, 10 mentions two instances of failure after 
resection, of false joints, without specifying the bones ope- 
rated on. 

Of the 38 cases in the table in which resection was per- 
formed, 24 were cured, 1 amended, 7 failed, and 6 died. Of 



these- 



12 were in the femur, of which 7 were cured. 

6 " leg, "5 " 
12 " humerus, "6 " 

7 " forearm, " 5 " and 1 amended. 
1 was " jaw, " 1 was " 

The longest period that the fracture had existed in these 
cases was 5 years (adult — femur). The shortest period was 
10 weeks (humerus, set. 50). 

The average period was 13 months and 19 days. 

The longest period required for the cure was 13 months 
(femur, set. 26). 

The shortest period was 1 month (forearm). The average 
period was 4 months. 

In 17 of the cases in which resection was employed, other 
methods of operating are stated to have been tried, and to 
have failed; of which the seton was used 6 times. 

In the 38 cases in which resection was resorted to, acci- 

1 Velpeau, op. citat., ii. p. 587. 2 System of Surgery. 

3 MS. Notes of Lectures. * Velpeau, op. citat., ii. p. 590. 

5 Idem, idem. 6 Jaeger's Thesis on Resections. 

7 These of Berard, p. 53. s Oppenheim, p. 11. 

9 Amer. Journ. Med. Sci., vol. v. N. S. 1843. 

10 Idem, p. 12. 



M 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 101 

dents dependent upon the treatment followed, and not termi- 
nating in death, occurred 9 times (erysipelas 6; profuse 
suppuration and abscesses 2 ; phlegmasia dolens 1). 

Despite the constitutional and operative measures for the 
relief of ununited fractures which have been passed in review, 
the following case, under the care of a late eminent hospital 
surgeon of London, Mr. Key, well shows that instances 
occasionally are met with in which all measures will prove 
ineffectual, however ably they may be carried out. 

" Henry Udred, set. twenty-five, a stout muscular man, by 
trade a butcher, who had never had syphilis nor taken mer- 
cury, and, in fact, never remembered a day's illness, broke his 
left humerus about its lower third on the 4th of November 
1839. The limb was at once put up in splints and bandages, 
which were removed and readjusted every other day for the 
first fortnight ; and after this once a week for six weeks, 
during which time he could occasionally distinctly feel the 
ends of the bone rub against each other. At the expiration 
of this time the bones were still ununited, and all treatment 
was abandoned for four weeks more. 

"He then consulted another surgeon, who secured the limb 
in splints, and kept him in bed for a month, but without avail. 

11 He next went to Eamsgate and bathed for six weeks, but, 
this being equally inefficacious, he became a patient in Guy's 
Hospital, under Mr. Key, on the 8th of July, 1840. 

"Every means that held out any prospect of producing 
union were made use of, but were all equally unattended 
with benefit. After the ordinary methods of perfect apposi- 
tion, rest, pressure, etc., had met with failure, Mr. Key cut 
down to the separated portions of bone, and attempted, by 
placing wire around their extremities, to excite periosteal 
inflammation and so to lead to the desired union. This not 
succeeding, he again divided down to the line of fracture, 
and, having exposed the surfaces of the disjoined portions 
of bone, removed a thin layer from each by means of a fine 
saw. On this occasion, a portion of substance, having a car- 
tilaginous appearance, apparently muscular tissue, which had 
become altered by pressure, was found separating the two 
extremities of the bone, and was removed. 



102 CONTRIBUTIONS TO PRACTICAL SURGERY. 

" This operation having proved unsuccessful, notwithstand- 
ing a considerable degree of inflammation was excited, as a 
dernier resort, a seton was passed between the separated 
surfaces. This, however, failed equally with the other 
attempts in producing union, and the man left the hospital 
unrelieved. At one period in the course of the treatment 
above mentioned, he was subjected to the influence of mercury 
until salivation was produced, but apparently without pro- 
ducing any effect on the fractured ends of the bone." 1 

A remarkable instance of a similar kind in the humerus, 
aged 47, occurred to M. Yelpeau, in which, after the immova- 
ble apparatus, frictions, and seton had been tried and failed, 
resection was done by him in the month of October, 1844, 
without benefit. In May, 1845, resection was a second time 
resorted to, after which the ends of the bones were drawn 
together and so retained by silver wire, but without any 
benefit. 2 

Another case, demonstrating the occasional futility of our 
most approved methods of treatment in ununited fractures, 
even in the most skilful hands, occurred to Sir Wm. Fergus- 
son. A fracture in the middle of the thigh, which had 
become firmly united with deformity, was rebroken and union 
failed to take place. Resort was had to scraping the ends of 
the fragments by means of a tenotomy knife, resection of the 
ends of the bones, and the ivory pegs, and all uselessly. The 
limb was ultimately amputated. 3 

From all that has been observed in the preceding pages 
upon the treatment of ununited fractures, it will be seen that 
we recommend : — 

1st. To apply the method of cure by rest and compression. 
If the fracture has been regularly treated, and is not consoli- 
dated at the usual period, replace the limb in the apparatus, 
and insure to it a state of complete immovability : if the 
treatment of the injury has been altogether neglected, or been 
inefficient, apply proper splints and moderate compression 

1 A. Cooper on Dislocations and Fractures. New edit., 8vo. Lond. 1842, 
p. 575. 

2 Gaz. des Hopiteaux, No. 5, 13th January, 1846. 
8 Med. Times, vol. xix. p. 33, 1859. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. 103 

with a roller, and renew these as soon as they become in any 
degree lax. 

2d. If, from want of action in the seat of injury, rest and 
compression are in themselves insufficient to produce a cure, 
continue the state of immobility in which you have placecl 
the limb, and apply blisters, moxas, iodine, or some other 
stimulant to the seat of fracture. 

3d. If both of these modes fail in producing a deposition 
of callus, employ frictions. 

4th. If the methods mentioned fail to produce a change, or 
the patient has already been suffering from his injury for 
eight or ten months, and there is no contra-indication to it, 
resort to the seton. 

5th. If the case be one to which, from its long standing, or 
state of the injured parts, the seton is inapplicable, expose 
the fracture, and apply caustic potash to the fractured ends. 

6th. If all the above means have been carefully resorted to 
unsuccessfully, and not till then, resect the ends of the bone. 

7th. Never resort to amputation of the member until fair 
trials have been made with all of these methods, and then 
only at the request of the sufferer, after he has found that the 
limb can be of no possible service to him. 

In employing any of the above means, the obstacle to the 
occurrence of union which may exist, arising from the state 
of the constitution, should be carefully sought for and com- 
bated by an appropriate treatment. 

APPENDIX. 

The accompanying table, arranged in such a manner as to 
exhibit the chief points in each individual case, together with 
the sources from whence they are derived, is added in proof 
of the remarks made in the foregoing pages. No reference 
is given which I have not myself examined, and the collec- 
tion, so far as the American, English, and French journals, 
and surgical works are concerned, will be found tolerably 
complete. A number of cases might, I doubt not, be added 
from the German, and it is a source of much regret, that but 
few works in that language were within my reach. 



104 



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110 CONTRIBUTIONS TO PRACTICAL SURGERY. 



SUMMARY. 

Of the above one hundred and fifty cases of ununited 
fractures — 

48 occurred in the femur, of which 31 were cured, 9 without henefit, 6 died, 2 result not stated. 
33 " in the leg, " 32 " 1 " 

48 " in the humerus, " 31 " 14 M 3 " 

19 " intheforearm, " 17 "1 "1 " 

2 " in the jaw, " 2 " 

Of 46 cases in which the seton 1 was employed, 36 were cured, 3 partial cures, 5 no benefit, 2 died. 
" 38 " resection " 24 "1 " 7 " 6 " 

" 36 " pressure and rest 29 "1 "6 " 

" 8 " caustic " 6 " 2 " 

" 11 « frictions " 11 " 

Of 11 cases in which other methods 3 were employed, 7 were cured, 1 received no benefit, 2 died, 
1 result not stated. 

The results in the preceding table exhibit, probably, with 
tolerable accuracy, the success of the seton and resection, 
though not of the other methods of treatment, which, being 
milder, were in several of the cases employed before the two 
just named and more severe ones were resorted to. Thus it 
would appear as if all the cases treated by frictions had been 
cured, whereas, in fact, in the 36 cases cured by the seton, 
frictions had been unsuccessfully tried in 8 of them; and in 
the 24 cases cured by resection, they had been equally una- 
vailing in 5 of them. This will be seen by referring to the 
table, but could not be exhibited in the summary without 
complicating it more than we desired. 

Of 112 cases in which the age is noted, there were — 

between 10 and 20 14 

u 20 and 30 53 

" 30 and 40 21 

above 40 24 

From the tables and summary the following conclusions 
may be drawn : — 

1 Including the methods of Weinhold, Somme, Oppenheim, and Seerig. 

2 Including all cases in which the ends of the bone were scraped, rasped, 
or excised. 

3 Iodine, 3, all cured ; Injections, 1, cured ; Erysipelas, 1, cured ; Hot 
Iron, 1, cured ; Amputation, 5, 1 cured, 2 died, 1 failed, 1 not stated. 



OCCURRENCE OF NON-UNION AFTER FRACTURES. Ill 

1st. That non-union after fracture is most common in the 
thigh and arm. 

2d. That the mortality after operations for its cure follows 
the same laws as after amputations and other great operations 
upon the extremities, viz., that the danger increases with the 
size of the limb operated on, and the nearness of the operation 
to the trunk ; the mortality after them being greater in the 
thigh and humerus than in the leg and forearm. 

3d. That the failures after operations for their relief are 
most frequent in the humerus. 

4th. That after operations for the cure of ununited fractures, 
failures are not more frequent in middle-aged and elderly than 
in younger subjects. 

5th. That the seton and its modifications is safer, speedier, 
and more successful than resection or caustic. 

6th. That incising the soft parts previous to passing the 
seton augments the danger of the method, though fewer failures 
occur after it. 

7th. That the cure by seton is not more certain by allowing 
it to remain for a very long period, while it exposes to 
accidents. 

8th. That it is least successful on the femur and humerus. 



112 CONTRIBUTIONS TO PRACTICAL SURGERY. 






ON THE TREATMENT OF DEFORMITIES FOLLOWING 
UNSUCCESSFULLY TREATED FRACTURES. 

Irregularly united fractures sometimes fall under the 
notice of the surgeon, attended with so much shortening or 
deformity as to render the limb unsightly, painful, or al- 
together useless, and although the sufferers in such cases are 
generally eager for relief, yet the general practice has been, 
at least in this country and Great Britain, to abstain from any 
operative measures for the remedying of such states. Opera- 
tions, however, have been often proposed and practised for 
the removal of vicious consolidations, and, believing them to 
be frequently remediable, we think it well to call the atten- 
tion of the profession to this interesting subject, by bringing 
to their notice the various methods by which it may be done, 
and recalling to memory the different numerous instances in 
which they have succeeded. 

The means proposed for the removal of deformities fol- 
lowing fractures, are of three kinds. The first consists in 
straightening a crooked limb by means of well-applied pres- 
sure ; the second, in re-fracturing the bone at the point of 
former injury in order by an after-treatment to give it a better 
direction ; and the third, in making a section of, or removing 
the projecting or angular portions of bone, which give rise to 
the deformity. 

1. Pressure and extension of the limb. — The researches of 
Duhamel, Breschet, Dupuytren, and others, upon the forma- 
tion of callus, have proved beyond cavil the possibility of 
straightening deformed limbs at considerable intervals after 
the occurrence of fractures, by means of pressure, conjoined 
with extension and counter-extension. This method, however, 
is applicable only to those cases in which the callus has not 
yet acquired all the solidity of bone, an event which in the 



DEFORMITIES AFTER FRACTURES. 113 

majority of cases does not occur till the fiftieth or sixtieth 
day. Dupuytren furnishes examples of limbs straightened by 
this method as late as the one hundred and twentieth day 
after the receipt of the injury, and fixes upon the sixtieth day 
as the medium time at which benefit is likely to be derived 
from it. In bringing about straightening of the limb, exten- 
sion and counter-extension are to be employed in the same 
manner as in cases of recent fracture, the lirnb being drawn 
down with some force every second or third day, care being 
taken at the same time to keep, by means of the extending 
apparatus, what is gained by these forcible efforts. 

Sometimes, however, when the callus is very yielding, the 
parts may be dragged at once to a better position, and so re- 
tained, though generally the contracted state of the muscles 
accompanying these cases prevents this being done. 

Extension and pressure made with the aid of machinery 
have also been successfully applied to the remedying of these 
as of other deformities, and sometimes with marked success. 
An instance of this is related in the Transactions of the Medi- 
cal Society of Lyons, by M. Desgranges. The case was that 
of a female, who being badly treated in a chirurgical point of 
view after a fracture of the leg, found the limb, at the end of 
four months, so crooked that she was obliged to walk on the 
exterior edge of the foot. M. D. undertook to remedy this 
defect, and by means of a machine, making well-applied pres- 
sure on the protuberant angle of the fracture, obtained perfect 
rectitude of the leg. 

A most instructive case has been reported by Dr. Michener, 
of Chester County, Pa., in which, after a fracture of the femur 
at its upper third, where the limb was considerably shortened 
and deformed, and the fractured part surrounded by a spongy 
callus of four or five inches in diameter, by means of exten- 
sion and counter-extension, aided by pressure over the pro- 
jecting point, applied ten weeks after the accident, the 
extremity was gradually brought into a good position and an 
excellent cure effected. 1 

1 Amer. Journ. of Med. Sci., vol. xv. new series, 1S48. 



114 CONTRIBUTIONS TO PRACTICAL SURGERY. 

2. Rupture of the Callus.— Among the ancients, some of the 
surgical writers of authority recommended and practised in 
these cases the rupturing of newly consolidated bones, while 
others strenuously opposed it. In modern times, the practice 
was revived by (Esterlen, and has received countenance from 
practitioners of eminence on the continent of Europe ; Eiche- 
rand, Dnpuytren, Yelpeau, and many others, admitting of its 
employment in certain extreme cases. Such being the case, 
it will be well to examine its claims to attention, and cast a 
retrospective glance at the judgments passed upon the method 
by the recognized authorities in our science, as well for the 
purpose of exposing its dangers, as of learning the benefits 
which in some cases may be derived from it. 

The earlier of the ancient writers who recommended the 
rupturing of the callus produced it by means of blows with 
a hammer or other similar means, the member being previ- 
ously covered, and, protected to prevent injury to the soft 
parts, and, when done in this manner, we can well conceive 
that it would be likely to be followed with serious conse- 
quences. Ehazes, who particularly noticed this practice 
among the surgeons of his time, boldly opposed it, urging the 
danger of fracturing the bone elsewhere than at the seat of 
'previous injury, and recommended the adoption of emollient 
applications, with pressure and extension in lieu of it. Haly 
Abbas speaks of an old man with a deformity following the 
consolidation of a fractured thigh, who died from the effects 
of the rupturing operation. 

Guy de Chauliac, in cases where the callus was not older 
than six months, recommends to break the bone again at the 
same point with the knee, after having used emollient and 
relaxing applications, and afterwards treating- it as a recent 
fracture. 

Ambrose Pare speaks of the operation only to condemn it, 
except in cases where the callus is still soft, and the extremity 
so much deformed as to hinder the patient from using it, and 
even in these instances, before proceeding to the straightening 
of the limb, he advises the softening of the new growth by 
means of plasters and emollients, for fear of breaking the 



DEFORMITIES AFTER FRACTURES. 115 

bone at some other point than that at which it had first given 
way. 

Fabricius Hildanus rejects the operation, affirming at the 
same time that neither Hippocrates nor Galen practised it, and 
supports his opinion against its employment by the experience 
of Pare', Jessen, Guy de Chauliac, Albucasis, and Avicenna, 
all of whom were opposed to the forcible rupturing of the 
bones after firm union. 

Purmann 1 recommends relaxing applications when the arm 
or leg presents deformities which are not of long duration, 
and afterwards extension of the member by means of certain 
instruments, as the glosso-comium. But, if the callus had 
already attained perfect firmness, after the use of the same 
topical applications, he advises rupturing of the bones at the 
point of previous fracture by means of a machine worked by 
a screw, which is accurately described by him. Passing over 
the opinions of many esteemed writers, though of less au- 
thority on the particular subject of which we are treating 
than those we have just quoted, it may be well to dwell for 
a few minutes on those of some of the authors who have 
written upon the subject nearer to our own times. 

Morgagni 2 speaks of the operation of rupturing the callus 
and straightening the limb, as having to his knowledge suc- 
ceeded in some cases, but at the same time adds, that an in- 
stance was known to him, in which the same operation upon 
the leg was followed by death. Duverney, who in an espe- 
cial manner studied the injuries to which the bones are liable, 
remarks, that deformity after fractures " has determined many 
to the expedient of breaking the thigh anew, in order to 
remedy it. But this operation has been unsuccessful, nay on 
the contrary even, they have been in a worse state than 
otherwise they would have been in." 3 

In a work in our own language which is deserving of more 
frequent reference than it now receives, we find the follow- 



ing :— 



1 (Esterlen, Sur la Rupture du Cal, p. 18. 

2 Epist. 56, p. 154 ; vol. ix. 8vo. Paris, 1824. 

3 Trans, by Ingham, p. 137. 



116 CONTRIBUTIONS TO PRACTICAL SURGERY. 

" The crooked limb left after a fracture is very common, 
and, admit the callus has been a month, but especially of a 
longer date, I see little likelihood of remedy. The breaking 
asunder forcibly the new cement at these times has, I think, 
but rarely answered. Nor are we sure, after this second rup- 
ture, of success. From the larger bones, as of the leg, but 
particularly of the thigh, thus served to gratify some more 
nice than prudent people, I have known abscesses arise, and 
the fracture, before simple, now made compound, by a new 
afflux of humors ; at length rigors and convulsions have ensued, 
and carried off the patient" — " others, though with less hazard 
to their lives, I have known fare little better as to the straight- 
ness of their limbs ; and some, after the pain they have hereby 
undergone, have been left worse than before." 1 Heister, 2 
however, thinks that "when the callus is tender, and the 
patient young and vigorous, the operation may be fairly 
attempted," but nevertheless hints, that, if the deformity 
and hindrance from the fracture are but slight, it is better 
to avoid the operation, as it is neither free from pain nor 
danger. 

In a fracture of the thigh badly treated, and cured with 
considerable shortening, Ten Haaff ruptured the callus and 
made a cure without shortening. 3 

To rupture the callus, (Esterlen employed a complicated 
machine modified from those of Purmann and Bosch, the 
principle of which consists in having a pad attached to a 
piece of plank which by means of screws is made to descend 
gradually, and press upon the convex surface of the callus, 
the deformed limb having been previously fixed upon another 
padded plank to which they are attached. A sketch of this 
machine is figured in his work, but all that is sufficient, where 
this process is adopted, is, to fix the limb to be operated on 
upon a firm mattress or table, while at the same time pressure 
is made suddenly and firmly by means of the hands or knee 
of the surgeon. A number of facts collected by (Esterlen 

1 Turner, vol. ii. p. 189, 90, 2d ed. Lond. 1725. 

2 System of Surges, p. 117. London, 1743. 

3 Dezeimeris, Diet. Histor., torn. ii. p. 678. 



DEFORMITIES AFTER FRACTURES. 117 

from the older writers, as well as those given by him as oc- 
curring either in his own practice, that of Bosch, or of other 
surgeons of his country, clearly show that the fracture fol- 
lowing the rupture of the callus is generally exempt from 
contusion, or other serious complication, and that it may be 
cured as readily as an ordinary simple fracture. Setting 
aside, however, the statement of the acknowledged advocate 
of this mode of practice, facts will at once present themselves 
to the mind of every surgeon to show the facility with which 
the callus of broken bones may be fractured, and the little 
danger attendant upon its rupture, previous to the deposit 
of that substance in its definite form, that is, previous to the 
lapse of four or five months, as well as to prove that bones 
recently consolidated give way more easily at the first point 
of injury than elsewhere. These facts are not unfrequently 
witnessed by patients refracturing their limbs by falls a con- 
siderable time after convalescence from previous like injuries, 
in whom, although in some cases produced by great violence 
and accompanied with much contusion, we find consolidation 
to proceed as regularly as after their first fracture. 

In considering the propriety of straightening or rupturing 
the callus, it becomes interesting to inquire into the degree 
of force requisite to produce it. M. Jacquemin in his Thesis, 1 
which is understood to embody the views of Dupuytren on 
this subject, has endeavored to represent by weights the force 
necessary to break the callus in its different periods, and the 
results of his experiments are in the highest degree interesting, 
as showing that, at a period when the fractured limb is ordi- 
narily removed from the retentive apparatus, rupture of the 
callus will occur upon the application of a moderate degree 
of force. 

The short end of a femur which was surrounded by a regu- 
lar callus, taken from an adult on the 45th day after a fracture, 
was fixed horizontally upon a table in such a way that the 
callus projected from it, a scale beam being attached to the 
extremity in which weights were gradually placed. At 56 
pounds the part bent without tearing, and at the 60th pound, 

1 No. 140. Paris, 1822, quoted from Laugier's Thesis. 



118 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



the callus was completely ruptured. In a second experiment 
a callus of 59 days was torn off at the 56th pound. In these 
experiments the bones have been used as levers to aid in 
breaking the callus, and the amount of force required has 
been, therefore, underestimated; nevertheless they show the 
tendency to give way when they do break at the previous 
point of fracture. 

Previous to the appearance of M. Jacquemin's work, Bosch 
and (Esterlen had experimented upon bones after fracture in 
a somewhat similar way, and conclusively proved that the 
callus, even when more ancient than in the experiments already 
cited, gave way upon the application of force sooner than the 
original bone. 

The leg of an ox, three years old, which had become firmly 
consolidated after fracture that had occurred 28 weeks pre- 
viously, with shortening of the limb to the extent of an inch 
and a half, was fixed by its extremities on two pieces of plank ; 
the screw of a jack was then applied on the convex surface of 
the callus, which was fractured by a few turns of its handle 
without the production of splinters. The bone of the oppo- 
site leg, treated in the same way, required the application of 
much more force to produce its fracture. 

The thigh of a goat two years old, which had been frac- 
tured fifteen months and a half previously, and become firmly 
consolidated with deformity, was submitted to the action of 
(Esterlen's machine, and after a few turns of the screw the 
callus was fractured transversely in its middle. In a third 
experiment, the humerus of a woman, aged 81, which was 
firmly united six weeks after its fracture, was fixed upon two 
blocks at a little distance one from the other, the callus pro- 
jecting between them, and by pressure made with a round 
stick held in the hands of the operator, a clean fracture of the 
callus was produced. 

Besides these direct experiments upon the callus, numerous 
observations of the accidental rupture of bones united after 
fracture might be adduced, to show that for a length of time 
after consolidation of the original injury, rupture of the callus 
is feasible, is generally cured promptly, and has been often 
followed by marked benefit to the patient. 



DEFORMITIES AFTER FRACTURES. 119 

The possibility of straightening or of rupturing the callus 
after its deposit being admitted, a question arises as to 
whether or not it should be preceded by any preparatory 
local treatment, with the view of producing softening of this 
substance. Nearly all of the older writers recommend the 
use of fomentations, cataplasms, ointments, mercurial plasters, 
or warm bathing, with a view not only to their relaxing effects 
upon the soft parts, but also for those upon the callus, which 
they believed to become more supple, and apt to give way 
more easily after their employment. Of these applications, 
the moderns have found some to be altogether without value, 
while others of them have been thought by practitioners of 
note to merit the notice claimed for them in certain stages of 
the formation of callus. According to Duhamel, the use of 
douche baths produces such powerful effects in mollifying re- 
cently deposited callus, as to bring about, if often repeated, 
the complete separation of the fractured fragments. Kichter 
asserts the repeated use of warm baths to be a powerful means 
of softening the callus of firmly consolidated fractures, par- 
ticularly in those of rather advanced age, and Brieske 1 and 
other writers affirm the use of the mineral waters of Carlsbad 
and Barege to produce in a remarkable degree softening of 
this substance. Dupuytren, too, whose practical judgment 
and close observation of facts must be unquestioned by all, 
was fully persuaded of their good effects, and never attempted 
the straightening of a deformed callus in the lower limbs 
without enveloping the part for several days previously in 
emollient cataplasms and strictly enjoining the use of local 
baths; so firm, indeed, was his conviction in the efficacy of 
bathing for this purpose, that M. Laugier 2 affirms, that for 
fear of producing this effect he has often refused to allow baths 
to his patients who were convalescing after fractures. These 
means, however, can be of avail only before the deposit of 
the definitive callus, and must be more useful the nearer we 
approach the period of original injury, and it would be evi- 

1 Gazette Medicale, June 8, 1839. 

2 Des Cals Difformes, These. Paris, 1841, p. 41. 



120 CONTRIBUTIONS TO PRACTICAL SURGERY. 

dently improper to delay for any length of time an attempt to 
rectify a bad position of a limb in order to make trial of them, 
where a comparatively long period had already elapsed from 
the occurrence of the accident. 

It is a matter of much importance to determine accurately 
the cases to which re-fracture of the limb is applicable — more 
particularly the precise degree of deformity demanding it, and 
the lapse of time after which it would be proper to undertake 
the operation. The recorded cases of the operation have been 
most generally in young and robust subjects where the callus 
was still recent, and where the deformity was either consider- 
able, or interfered more or less with the use of the member. 
The procedure, however, is not adapted to all cases of irregu- 
larly united bones. It is only where an angular deformity 
exists, arising from the union of the fragments by their ex- 
tremities, that rupture of the uniting medium can be attempted 
with any good prospect of success. Where there is shortening 
of the extremity from the ends of the bones slipping past each 
other, even supposing that the rupture could be effected, union 
in the majority of cases would not follow in consequence of 
the extremities having become rounded and smooth. 

The observations of rupture of the callus, detailed in the 
work of (Esterlen, either by the hand alone, or with the aid 
of a machine, amount to seventeen in number, of which, ten 
were in the femur, five upon the leg, and two on the arm, in 
none of which did any very severe symptoms follow the ope- 
ration. Seven of these seventeen cases were in children, and 
ten in adults. The greatest length of time which had elapsed 
between the period of fracture and that of the operation, was 
six months, the shortest time, one month. The longest period 
required for the cure after rupture, was twenty weeks, the 
shortest period, four weeks, and in most of the cases operated 
on, very considerable deformity and shortening are stated to 
have been present. In no case did union fail to take place 
after it, and in all great benefit is reported to have followed it. 
In the Gazette Medicate for 1840, three cases are detailed 
by Mr. Pfluger, which go to confirm completely the statements 



DEFORMITIES AFTER FRACTURES. 121 

made by (Esterlen. The first was the case of a man astat. 64, 
who fractured his leg, and who, in consequence of bad treat- 
ment, was unable afterwards to walk without crutches. The 
patient desired to have the leg broken over, which operation 
was done by M. Bosch, after the method of (Esterlen ; it had 
perfect success, and ten weeks after the new fracture the 
patient could walk well, having but slight shortening. 

The second case was that of a boy astat. 16, with a fracture 
of the femur in its middle part. Consolidation had taken 
place with the fragments crossing each other, with inclination 
of the inferior end outwards and forwards, and shortening to 
the extent of eleven centimetres ; artificial rupture was prac- 
tised, and extension afterwards made use of. In two months, 
consolidation was perfect, the two members being of equal 
length. 

The third case was a youth oatat. 17, with fractured femur, 
the fragments of which had united at a considerable angle. 
The limb was shortened eight centimetres, and the patient was 
scarcely able to touch the ground with the point of his toes. 
Eighteen weeks after the accident, Dr. Gruel ruptured the 
callus with the machine of (Esterlen. Extension was after- 
wards made upon the limb, and at the end of three months 
the patient was moving about on crutches, with a shortening 
of only six millimetres. 

M. A. Thierry has recorded 1 the case of a fractured radius 
which was straightened by rupturing the callus, after perfect 
consolidation attended with much deformity. 

Dr. Mussey, in a case of deformed and useless leg, resulting 
from a fracture, ruptured the callus and straightened the 
limb several months after the injury, and in two months the 
bones were firmly consolidated in a good position. 2 

Mr. Butcher relates a case of fractured femur, aged 19, in 
the upper third, attended with shortening and great deformity, 
in which the union at the end of thirty days was firm enough 
to allow the entire weight of the body to be borne upon the 

1 L'Experience, Nov. 1841. 

2 Amer. Jonrn. Med. Sci., vol. xxi., New Series, 1851. 
9 



122 CONTRIBUTIONS TO PRACTICAL SURGERY. 

limb, where re-fracture was resorted to, and resulted in a cure 
so perfect that not the slightest halt or trace of the original 
deformity was perceptible. 1 

Dr. Gurdon Buck, of New York, has reported six cases of 
fractures of the femur, all of them accompanied with con- 
siderable deformity and shortening, in which he resorted to 
re-fracture: of these cases, one was aged five years, and the 
fracture of five months' standing ; three were aged nineteen, 
two of them being of six, and one of eight, weeks' duration ; 
one aged twenty-one, five weeks after the accident; and one 
twenty nine, sixteen weeks after the accident: and in all of 
them succeeded in making good cures. The rupture in all 
these cases was made with the hands, at the same time that 
extension and counter-extension was resorted to, and in none 
of them was the procedure followed by inflammation sufficient 
to prevent the immediate application of means to keep the 
limbs extended. In two of the cases, aged respectively nine- 
teen and twenty-nine, no motion existed at the seat of frac- 
tures. 2 

Mr. Skey believes that re-fracture of the bones may be 
effected without difficulty or danger at a term beyond that 
usually prescribed as the limit at which it is justifiable. He 
relates six cases — two of the thigh, at the periods of 77 and 
75 days from the date of the injury — two of both bones of 
the leg at the 74th and 45th days (the latter in a child six 
years of age), and one of both bones of the forearm at the 
expiration of 120 days, in which all did well. In another 
case the attempt to re-fracture a thigh at the end of nine 
months was unsuccessful. 3 

According to Velpeau, 4 M. Jacquemin proves that the dan- 
gers of artificial rupture have been singularly exaggerated, 
and he himself thinks it shown beyond question, that bones 
newly consolidated are more easily fractured at the point of 

1 Operative and Conservative Surgery, p. 481, 1865. 

2 Trans, of N. Y. Acad, of Medicine, vol. i., 1855. 

3 Med. Times and Gaz., Jan. 22d, 1859. 

4 Medecine Operatoire, 2d ed., 1839, torn. i. 



DEFORMITIES AFTER FRACTURES. 123 

primitive injury than elsewhere, and holds as a general rule, 
that the second fracture becomes consolidated more easily and 
promptly than the primitive one. He would limit us, how- 
ever, to three months, for attempts upon limbs presenting 
simple shortening from the fragments passing each other, 
though he looks upon efforts to rupture angular deformities 
always allowable, however long the period which may have 
elapsed since consolidation has occurred. 

Though generally unattended with dangerous consequences, 
yet still it is well to recollect that these have occasionally 
followed rupturing of the callus. Haly Abbas, as already 
mentioned, relates that in an old man of .70 years of age, 
where a re-fracture was made to remedy a deformed thigh, 
death occurred from the effects of the operation. Morgagni 
gives a like instance, and Laugier asserts, 1 that a similar re- 
sult has been observed in Germany. The callus in this case 
was of nine months' duration, and the femur the seat of the 
injury ; the re-fracture was produced by strong extension 
made with the pulleys, and death followed an hour and a half 
after the operation. 

Dr. Whitridge has published a case of fracture of both 
bones in the middle of the forearm which had united with 
great deformity of the limb, where the callus was broken up, 
and the fracture afterwards well treated by suitable splints, 
but no union ever took place, the arm remaining almost as 
flexible at the point of injury as at the wrist. 2 

Dr. Hunt 3 gives a case where a sailor fell from the rigging, 
and broke both bones of the leg about the middle. He was 
treated at sea for three weeks and then in an English hospital. 
Eemarkably firm bony union had taken place and great angu- 
lar deformity, only a limited portion of the internal edge of 
the foot could be brought to the ground. A small external 
incision was made and a large sized drill applied to the bone, 
perforating it in three or four different directions. The bone 
was then snapped asunder by manual force, the fracture taking 
place with a loud crack. The tendo Achillis was then di- 

1 Loc. cit., p. 62. 

2 New England Med. Rev. and Journ., vol. i., 1827. 

3 Pkila. Med. Times, vol. iii., 1872. 



124 CONTRIBUTIONS TO PRACTICAL SURGERY. 

vided subcutaneously and the limb with an external paste- 
board splint put at rest in a fracture box. There was great 
shock at first, followed by hepatitis, pleurisy, and a deep gan- 
grenous slough at the wound. Several pieces of bone came 
away ; for a time his life was despaired of, but the symptoms 
ameliorated gradually, the wound healed, and the fracture be- 
came firmly united in good position. I am informed by Dr. H. 
that a year after his discharge from the hospital he had been 
doing full duty as a seaman for several months. 

The treatment after re-fracture of a bone in no way differs 
from that usually employed in ordinary solutions of continuity 
of the bony fibre. If possible, the limb should be at once 
stretched to its proper length, or at any rate brought into a 
good position, and so retained by means of an appropriate 
apparatus, till the consolidation is effected, care being taken, 
where much shortening has existed, to make the extension in 
such a way as not to provoke severe inflammatory action. 

3. Resection. — In cases where objection has been made to 
rupture of the callus, where this is impossible to attain by the 
application of a safe degree of force, or where the deformity 
is of very long standing, and the union has taken place at any 
considerable angle, division, or resection of a portion of the 
bone, has in numerous instances been performed, and followed 
with successful results. As these operations do not appear to 
have received the attention which they merit, the following 
abstract of them, embracing many of those to be found re- 
corded, is given. 

Eesection of a projecting portion of the femur, following a 
badly set fracture, is reported to have been successfully prac- 
tised in 1521, upon the famous Jesuit, Ignatius de Loyola, 
then aged 28 years. 

Gardiel, the translator of Hippocrates, relates in that work, 
that, in the case of his own nephew, a like resection was per- 
formed on the bones of the forearm, and that the operation 
was perfectly successful. 

Wasserfuhr, of Stettin, 1 in 1816, separated and resected the 
femur, in a child aged five years, to remedy an angular de- 

1 Lancet, vol. i., 1828-29, p. 521, from Rust's Magazine. 



DEFORMITIES AFTER FRACTURES. 125 

formity of that bone above its middle part, following a badly 
set fracture. The fractured bone was consolidated in such a 
manner as to form nearly a right angle, and the limb was 
shortened to the extent of twelve fingers' breadth. The opera- 
tion was difficult, and followed by severe symptoms, but the 
patient recovered. We must here remark, that, though suc- 
cessful, we do not think any similar operation to be either 
called for or ever justifiable in a child of five years. 

Eiecke, in 1827, l in a patient aged 20, with a badly united 
fracture of the femur — the limb being shortened nearly a foot 
— incised the soft parts from the great trochanter to the ex- 
ternal condyle, divided the callus with a saw, and afterwards 
removed the end of the superior fragment of the bone. A 
perfect cure was obtained in eight months, the member 
having been restored by permanent extension to nearly its 
natural length. 

M. Clemot, 2 surgeon-in-chief of the marine at Eochefort, 
has in two instances resected portions of the femur, in order 
to remove great deformities resulting from badly treated 
fractures. The first case was in a child in whom the treat- 
ment by extension, though persisted in for several months, 
had failed. The operation was done in December, 1834. A 
longitudinal incision, two inches in length, was made over 
the callus, and the bony angle fairly exposed. The fragments 
had united at an angle of about 112 degrees. Spatulas were 
placed beneath the bone in opposite directions, in order to 
protect the soft parts, and the angular projection protruded. 
With a small saw, a section perpendicular to the axis of the 
superior fragment was made, including but two-thirds of its 
thickness. A like section was then made for the inferior 
fragment. The loss of substance was not great, and was at 
the expense of the callus. The limb was then placed in a 
good position, and the fragments maintained in apposition. 
Seventy days after the operation the child was removed to 
Bordeaux, having the limb straightened and lengthened. 

The second case was that of a husbandman, satat. 27, who, 

' Archives Generates, September, 1828. 
2 Arch. Generates, 2me ser., torn. ii. p. 235. 



126 CONTRIBUTIONS TO PRACTICAL SURGERY. 

fourteen months and a half previous to the operation, had met 
with a fracture of the left thigh, a little above its middle. 
After the cure, the femur remained deformed, and bent to an 
angle of 130 degrees — the summit of this appearing at the 
external and anterior part. The limb was shortened five 
inches ; the leg and the foot carried inwards, and the patient 
unable to walk. The callus was perfectly firm. Kesection of 
the angular projection was made in February, 1835, and the 
limb afterwards placed on a double inclined plane. Seventy 
days after the operation, the inclined plane was removed, the 
leg and thigh being still kept in a state of semi-flexion, and 
but slight motion allowed. The date of his discharge is not 
mentioned, though it is stated that he was able to support the 
weight of his body on the limb, and had a lameness scarcely 
perceptible. 

In a case of deformity after a fractured leg, in which the 
sharp edge of the tibia projected against the skin, so as to 
occasion much pain and deformity, and considerable difficulty 
in setting the foot against the ground, Mr. Dunn, of Scarbo- 
rough, 1 in 1821, made a semilunar incision of the integuments, 
turned them backwards, and with Hey's saw amputated the 
sharp angle of the bone. The leg by this course was made 
much straighter, and the patient afterwards walked well. 

In 1827, a case fell under the notice of Mr. Duncan, 2 in 
which a fragment of the femur of a man aged 22 projected 
outwardly, at a point above the middle of the thigh, to so 
great a degree that it seemed scarcely covered by soft parts, 
and formed with the other portion of the bone nearly a right 
angle. This deformity had followed the treatment of a com- 
pound fracture of the thigh received a year previously, and 
almost entirely prevented the man from walking. Mr. D., 
after exposing this projecting piece of bone, which was ex- 
ternally sharp and nearly an inch and a half in length, cut it 
off with a large pair of bone-pliers. The edges of the wound 
united by the first intention, and the patient did well. 

In 1823, Dr. Warren, of Boston (communicated to author by 

1 Medico-Chirurgical Transactions, vol. xii. p. 181. 

2 Lancet, 1827-8, vol. i. p. 25. 



DEFORMITIES AFTER FRACTURES. 127 

Dr. J. Mason Warren), sawed out a cuneiform fragment of the 
tibia at its most prominent part, in a case of deformity follow- 
ing a fracture which had occurred nine months previously at 
sea. The patient was 22 years old, and the leg was greatly 
curved inwards. After removal of the wedge, the base of 
which was two inches in length, the fibula was broken by 
manual force, and the parts straightened and secured by splints. 
The union was perfected in four weeks. 

Dr. Parry, of Indiana, 1 in a young subject, who had met 
with a fractured leg two years before, which had been suffered 
to unite at an angle almost equal to a right angle, in 1838 
exposed the bones, and sawed a little cuneiform block out of 
the angle of each; in a little more than two months after, the 
patient was discharged cured, the leg being straightened and 
increased three inches in length. 

Mr. Key, in October, 1838, 2 performed a similar operation 
upon a gentleman who met with a fracture of the tibia in 
August, 1835. The shortening occasioned by the deformity 
in this case was such as to cause the patient to walk on his 
toes, the heel being raised an inch and a half when he stood 
upright. The tibia was divided on the 14th of October, and 
by the 18th of January following the bone had firmly united, 
the limb having acquired a good position and appearing but 
little less than its fellow. 

Professor Portal, of Palermo, 3 has also operated successfully 
on two like cases. The first was in a patient aged 32, in whom 
a fracture of both bones of the leg, near their middle, had 
united in an irregular manner. An incision was made over 
the angular projection, and about an inch of the bone removed 
by the chain-saw. The limb was then carefully extended, 
and a cure procured in forty-eight days, the wound having 
united by the first intention. "Very little shortening occurred. 

The second case was that of a woman in whom the fractured 
ends of the femur had united so as to form an angle at the 
point of union. The ends of the bone were cut down on, and 

1 Am. Journ. of Med. Sci., vol. ix. 1839. 

2 Guy's Hospital Reports, April, 1839. 

a Am. Journ. of Med. Sci., vol. iii. N. S. 1842. 



128 CONTRIBUTIONS TO PRACTICAL SURGERY. 

an inch and a half removed from the upper fragment, after 
which half an inch was sawn off from the lower. The limb 
was maintained in a state of permanent extension. Fifty-five 
days afterwards she was dismissed cured, with the limb per- 
fectly serviceable, though shortened to the extent of two finger- 
breadths. 

In 1839, a boy aged fourteen years fell under the notice of 
Dr. Stevens (communicated in a letter from Dr. "Watson, of 
New York), in whom the leg had been fractured eight years 
previously, and had been suffered to unite in such a way that 
its lower part was bent inwards and backwards, nearly at 
right angles with the upper. For the purpose of remedying 
this deformity, Dr. S., after exposing the bones, sawed out a 
wedge-shaped piece from the angle of the tibia, and another 
from that in the fibula, and then, after a subcutaneous division 
of the tendo Achillis, straightened the leg and brought the 
bones into careful apposition. The case was subsequently 
treated as one of compound fracture, at first by Amesbury's 
apparatus, and afterwards by the starched bandage. Notwith- 
standing every attention, however, union failed to occur, and, 
about a year after the attempt to straighten the limb had been 
made, amputation became necessary, and was successfully done 
by Dr. Watson. 

In a patient 23 years of age, affected with a deformed and 
shortened leg consequent upon an unsuccessfully treated frac- 
ture, received ten months previously, Dr. Thomas D. Mutter 1 
resected the extremities of the bones with success, the patient 
walking without difficulty eight months after the operation. 

In 1841 Dr. J. E. Barton 2 operated for the relief of deformi ty 
of the leg following a fracture. In this case, the extremity of 
the upper fragment of the tibia projected inwards, overlapping 
the lower one about half an inch, and the limb, besides being 
shortened and deformed, was weakened, and the footing of the 
patient rendered uncertain, the whole foot being thrown out- 
wards. The parts being exposed, the extreme ends of the bone 
were sawn off, and the transverse bridges which connected the 

1 Am. Journ. of Med. Sci., vol. iii. N. S. 1842. 

2 Medical Examiner, No. 2, 1842. 



DEFORMITIES AFTER FRACTURES. 129 

tibia and fibula together were removed by the chisel and bone- 
nippers, and the fragments brought into perfect coaptation, and 
so retained. By the end of the fourth week, bony union was 
so far advanced as to admit of the limb being rolled about the 
pillow, and on the fortieth day he arose from his bed with a 
straight and sound limb. 

Josse, of Amiens, in 1845, operated on a boy aged 13, who 
several years before had met with a fracture of both bones of 
the leg, which had become consolidated with acute angular 
deformity so as to prevent all locomotion. A wedge-like 
piece of bone was removed, and a cure with a shortened but 
useful limb resulted. 1 

Mr. Rynd, of Dublin, gives an instance of a badly united 
fracture of both bones of the leg, in its lower third, in a man 
aged 28, of three years' standing, in which he sawed off the 
angular portions of the bones. The operation was done in 
July, and so severe were the symptoms that followed (hectic, 
• profuse discharge, etc.), that in the month of September ampu- 
tation of the limb was proposed to the patient, but refused, 
and, after struggling on, living on tonics, wine, porter, etc., 
a piece of the tibia was found to be necrosed in the month of 
October, and was removed. From this time he improved, and 
got well, with a perfectly straight and useful leg. 

Another case of resection of the femur for an irregularly 
united fracture, followed by a successful result, has been made 
known by Dr. Dorsey, of Ohio, in the Western Lancet for May, 
1848. 

In a case occurring in a young man, in the middle of the 
femur, attended with much deformity, Dr. Crompton made a 
resection with success; firm union occurring in three months, 

7 O 7 

and the limb straight and but slightly shortened. 2 

Dr. Brainard proposed and put in execution in 1858 a new 
method of treatment for irregularity of bones resulting from 
badly treated fractures. This consists in weakening the bone 
by subcutaneous perforation, and causing it to soften by the 
inflammation thus excited, and then straightening it by pres- 

1 Malgaigne's Journ. de Ckirurgie, 1845, p. 300. 

2 New Orleans Journ., vol. v., 1848-9. 



130 CONTRIBUTIONS TO PRACTICAL SURGERY. 

sure. The case was in the leg, in a child aged three, and had 
existed for three months. The bone was perforated in two 
different directions, and the rupture attempted by laying the 
leg on a firm bed with the. hands "by throwing nearly the 
whole weight of my body upon it." It did not, however, yield 
in the slightest degree. At the end of ten days, after the in- 
flammation, which was considerable, had subsided, another 
attempt to straighten the leg was made and he was somewhat 
surprised to find that a very moderate degree of force, applied 
by the hands, was sufficient to cause the callus to give way. 
A bandage and curved splint were then applied for four weeks, 
at the end of which time the limb was straight. Three months 
afterwards the splint was thrown aside, and the cure complete. 1 

The following cases, taken in connection with those quoted 
in a former part of this paper (p. 123), showing that ill effects, 
and even death, may follow the simple rupturing of the callus, 
put in a strong light the necessity for great care before ad- 
vising a resort to the practice. 

In 1850 Dr. Horner resected a part of the femur in a case 
of fracture, which had happened eighteen months previously, 
and had united, with deformity, the bone being bent angu- 
larly on its outer side and the limb shortened, and afterwards 
made use of powerful extension with pulleys to overcome the 
shortening, and place the fresh surfaces in contact. Mortifi- 
cation of the limb followed, which terminated in death on the 
fourth day. 2 In a case of angular deformity at the junction of 
the upper with the middle third of the femur, occasioning a 
shortening to the extent of four inches, Mr. Gay, of London, 
ruptured the callus about a twelvemonth after the accident. 
Finding, after this procedure, that it was impossible to place 
the fragments in a better position than they were before, he, 
after the lapse of a few days, resected the ends of the bone, 
and placed the limb on a splint. Ten weeks after resection, in 
consequence of exhaustion and serious constitutional disturb- 
ance, amputation was done, and the patient died while the 

1 Amer. Journ. Med. Sci., April, 1859. 

2 Med. Examiner, Philadelphia, vol. vii., N. S., 1851. 



DEFORMITIES AFTER FRACTURES. 131 

vessels were being secured. 1 Another like case, where a frac- 
ture in the middle of the femur had united in such bad posi- 
tion that it was re-broken and no union took place, notwith- 
standing three different modes of operative relief were resorted 
to, occurred to Sir William Fergusson, and was amputated by 
him unsuccessfully. 2 

After the cure of fractures, points of new bone are at times 
thrown out in such a way as either to give rise to much suffer- 
ing, or prevent proper motion in the joints, and in these cases 
operative measures have been resorted to for their cure. Mr. 
Alcock 3 relates the case of a gentleman who, in 1835, was thrown 
from a gig, and fractured the upper third of the ulna into the 
elbow-joint. Considerable swelling supervened, and the fracture 
was not discovered until some union had taken place, and that at 
such an angle that a sharp peak projected at the posterior sur- 
face, rendering any attempt at flexion painful in the extreme, 
from the stretching of the skin over the sharp end of bone. 
Gentle passive motion and friction had been adopted, but the 
time had arrived, Mr. A. believed, when more force was re- 
quired, and no perceptible advantage could be gained without 
it. This opinion was founded upon the diagnosis, that mere 
ligamentous bands, uniting the fragments at an angle, pre- 
vented the flexion of the arm, and that it required regulated 
but considerable force to elongate these, and, before it could 
be attempted, removal of the projecting sharp end of the bone 
was necessary. Sir A. Cooper concurring in this view of the 
case, the projecting end of the bone was removed, and, as soon 
as the wound was healed, a moderate degree of forcible ex- 
tension was employed. The case rapidly improved, and he 
recovered the perfect use of the part. 

A nearly similar operation was done with success, at the 
urgent request of the patient, upon a female at La Charite, by 
M. Velpeau, 4 and a like method is said to have been employed 
upon the femur in England, by Mr. Dawson, with happy result. 

1 Lancet, vol. ii., 1850, p. 456. 

2 Lancet, vol. ii., 1850, p. 653. 

3 Medico-Chirurg. Transactions, vol. xxiii. p. 315. 

4 Med. Operat. 2eme ed., tom. ii. p. 559. 



132 CONTRIBUTIONS TO PRACTICAL SURGERY. 



STATISTICS OF FRACTURES AND DISLOCATIONS TREATED IN 

THE PENNSYLVANIA HOSPITAL, DURING THE TWENTY 

YEARS FROM 1830 TO 1850. 

During the twenty years from 1830 to 1850, a large number 
of fractures and dislocations were received at the Pennsylvania 
Hospital, and, without having any novelties regarding their 
treatment to make known, I have thought it would be of 
interest to present a statistical account of them, with the view 
of showing their relative frequency and the results obtained 
there during a long term of years. 

In these tables no separate head is retained for compound 
fractures, except those of the thigh ; the entries having been 
so made in the books of the hospital, that it was impossible 
when they were begun in all cases accurately to ascertain 
whether the patient was admitted for simple or compound 
fracture ; and for the same reason, under the heads of fracture 
of the arm and fracture of the leg, are included respectively 
those of the forearm, either of one or both bones, as well as of 
the humerus, and of one or both bones of the leg. As has 
ever been the case, surgeons are still divided in opinion as 
to the best method of treating fractures of the extremities. 
Volume after volume has been written to show the propriety 
of one or another mode of treatment, but in few instances only 
has an appeal to a large number of facts been made to justify 
the recommendations that have been given of them. To 
public institutions it is, that we must principally look for sta- 
tistical information in regard to these injuries, and, although 
our records on this subject are so imperfect as to give only 
general results, still we look upon them as of some interest, 
and have prefaced them with a concise account of the plan of 
treatment generally adopted in these accidents, during the time 
mentioned. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 133 

Femur. — In the treatment of most fractures of the thigh, the 
straight position was preferred, and the apparatus of Desault 
modified was that mostly employed. The improvement consists 
in the greater length of the outer splint, and the attachment 
to its lower end of a small block, over a notch in which the 
extending band passes, in order that the extension be made in 
a line with the axis of the limb. If the limb can be at once 
brought down to its natural length, it in all cases should be 
done on the first application of the apparatus; but, when there 
is so much muscular contraction as to render this very pain- 
ful, the limb need not be drawn to its full length at first. In 
these cases it should be extended as much as possible, and, at 
the second visit of the surgeon, should be seized at the ankle, 
and slowly pulled downwards, while an assistant tightens and 
makes fast the extending band. This course is to be repeated 
until the fragments are perfectly reduced, which may in most 
cases be readily done at the end of twelve or eighteen hours. 
No great advantage is believed to be gained by the employ- 
ment of short splints, or bandages of any sort, applied imme- 
diately to the thigh, and their use is dispensed with, as they 
prevent the surgeon from accurately examining the state ot 
the fracture, and require that the limb should be disturbed in 
order to reapply them. A long narrow bag, stuffed pretty 
firmly with cotton, and covered with buckskin, is used for the 
counter-extending band ; and a double buckskin gaiter, with 
a thin layer of carded cotton laid over it, or a buckskin band 
lined with linen, is made use of for the extension. 1 Extension 

1 Since the period included in these tables bands of adhesive plaster reach- 
ing from just below the knee to two inches below the plantar surface of the 
foot, and there fastened to a thin piece of board two inches square, have been 
introduced, and form an admirable method of extension. To prevent slip- 
ping, the longitudinal bands are confined by two or three adhesive strips 
encircling the leg. If the cord running from this be conducted over a pulley 
fixed at the foot of the bed and attached to a weight, or a bag partially filled 
with shot, we have a uniform and constantly acting extension ; and when 
this form of apparatus is adopted sand-bags placed at the sides of the limb 
(extending from the hip to beyond the foot) are a simple and efficient mode 
of replacing the apparatus of Desault ; or, if preferred, the same method of 
extension can be employed with the last-named method. 



134 CONTRIBUTIONS TO PRACTICAL SURGERY. 

violent enough to cause pain should never be made use of; it 
ought always to be moderate, steady, and permanent. If con- 
stant pain is complained of at any point on which the dress- 
ings press, it should be immediately examined and readjusted. 
The restlessness of patients causes any apparatus to be easily 
displaced, and it is therefore necessary to smooth, tighten, and 
carefully re-examine it daily. Excoriation of the heel is 
most frequently produced by want of care in not having the 
extending band smoothly applied to the part, or by tightening 
it in too great a degree without having previously drawn 
down the limb with the hand. Sometimes, however, excoria- 
tion is caused by the weight of the foot alone; and in these 
cases the application of a piece of kid, spread with soap cerate, 
will mostly prevent it. 

In fractures of the femur within the capsular ligament, the 
application of any splints in the treatment is discarded — the 
limbs being merely supported by pillows in the extended 
position. No case has been observed in the period comprised 
in this report, in which the toes were thrown inwards. Seve- 
ral instances of fractures about the hip-joint, in persons of 
middle age, have come under notice, in which, even with the 
most accurate examination and measurement, it was impossi- 
ble to detect any crepitus or shortening of the limb till after 
the lapse of one or more days. 

Although the signs by which fractures of the neck of the 
thigh-bone and luxations may be distinguished from each 
other, and from simple contusions, are dwelt upon in our 
treatises, and are made out to be readily distinguishable, and 
well marked, yet all practical surgeons are aware of the diffi- 
culties of diagnosis sometimes attendant upon the various 
injuries about the hip upon actual inspection. The true 
nature of the injury in these cases is often more evident some 
time after the receipt of the accident than immediately upon 
its occurrence, and I am inclined to think that the necessity 
of close secondary examinations, in all instances in which there 
is room for a doubt as to the nature of the injury, are not suf- 
ficiently insisted on. The following cases, which came under 



STATISTICS OF FRACTURES AND DISLOCATIONS. 135 

notice, are well calculated to show the necessity of close and 
repeated examinations in injuries of this part. 

John Henrick, aged 52, was admitted November 27th, 1831, 
for an injury of the hip received by falling down a few steps. 
He complained of excessive pain about the joint, and was unable 
to rise, or in any way move the limb. Accurate measurement 
from the anterior superior spinous process to the malleolus 
showed the limb to be of the same length as that of the oppo- 
site side. No deformity existed about the joint, no crepitus 
could be detected, and the toes were not thrown outwards. 
The injury was looked upon as a contusion, and rest and the 
application of a few cups were the remedies prescribed. 

On the fifth day after his admission he had an attack of 
mania-a-potu, and during his delirium was out of bed, stood 
upon and moved his limb considerably. Having recovered 
from this attack, he was sent back, from the room to which he 
had been removed, to the surgical ward, and it was then found 
that the limb was shortened a full inch and a half, and the 
knee and toes everted, though a daily examination of the part 
up to the time of this attack showed nothing amiss about it. 
The case now was ascertained to be a fracture through the 
great trochanter. 

In January, 1831, another case, very similar to the above, 
occurred in a patient aged 38. "When admitted, he complained 
of great pain in the hip, but the toes were not everted ; no 
crepitus could be detected, and upon careful measurement no 
shortening of the limb was observable. A short time after 
his entrance, he also was attacked with mania-a-potu, and on 
recovery shortening was discovered. Long splints were ap- 
plied, with the effect of counteracting in a measure the shorten- 
ing, and the man left the hospital in April, walking with a 
stick. 

The exact length of the limb on entrance, with the natural 
position of the foot, and absence of any deformity or crepitus, 
led to the supposition, in both the above cases, despite the 
great pain suffered, that simple contusions only of the part 
existed, and this idea was confirmed at the commencement of 
the attacks of their delirium, upon seeing the men up and 



136 CONTRIBUTIONS TO PRACTICAL SURGERY. 

moving about the room; but, after recovery from their deli- 
rium, the eversion of the foot led to an immediate examina- 
tion, when the shortening was found to exist, which, in 
connection with the symptom just mentioned, could only be 
caused by fracture of the neck of the bone. In both cases 
the fragments must have been interlocked in such a way as to 
have prevented any shortening or motion, and so remained 
till the delirium occurred, when the violent efforts made to 
use the limb unlocked the parts, and permitted the lower 
fragment to be drawn upwards. 

Previously to witnessing these cases I had believed it im- 
possible for a patient with fracture of the neck of the femur 
to walk upon the limb, but, upon examining the records of 
our science upon this point, I find that similar instances are 
noted. Sabatier 1 has recorded an instance in which the patient 
walked home, and even got up the next morning, after an 
injury of this kind. Desault has seen similar cases. 2 Boyer 
states that he saw a man who was able to walk with the aid 
of a stick during several days after a like accident; 3 and Dr. 
McTyer 4 details a case which had not confined the patient from 
her usual occupations, but which, was proved on dissection, 
three months after, to be a case of fracture within the capsular 
ligament. 

Since the occurrence of the cases I have described, Mr. 
Syme 5 and M. Malle, in his Clinique Chirurgicale, have each 
given a case of fractured neck of the thigh, in which the 
patients walked some distance after it. Dr. Hunt details 
one of intra-capsular fracture of the femur in a young man, 
where he walked several hundred yards after the accident. 
He died subsequently from pelvic abscess and pyaemia, the 
result of the severe contusion received at the time of the acci- 
dent, and the autopsy verified the diagnosis. 6 I have myself 
seen another hospital patient, with a similar fracture (proved 

1 Memoires de l'Acad. de Clrirurg., torn. iv. 8vo. 

2 CEuvres Chirurgicales, torn. i. 

3 Mai. Chirurgicales, 4eme edit., torn. iii. 

4 Glasgow Med. Journ., vol. iv. 

5 Edin. Med. and Surg. Journ. for 1836. 6 Loc. citat. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 137 

by post-mortem examination), who assured me that he had 
walked some squares after the occurrence of his accident. 

Ley. — In the treatment of fractures of the leg, as in those 
of the thigh, splints or bandages are rarely applied to the 
limb. The leg is placed in a fracture-box upon a well-stuffed 
pillow, in such a manner as to bring the sole of the foot in 
contact with the foot-board. The fractured bones are then 
accurately adjusted, and the sides of the box are tied together 
moderately tight. The foot is securely fastened to the foot- 
board by means of a strip of bandage, in order to prevent its 
falling to either side, and the pressure of the pillow is, in 
the vast majority of cases, quite sufficient to retain the frag- 
ments in their natural position. The foot-board of the box is 
set into its bottom nearly straight, and is made to project be- 
yond the foot, in order to prevent the toes from falling down- 
wards, and thus cause a projection forwards of the upper end 
of the lower fragment. 

Severe inflammation so frequently follows these fractures, 
in consequence of most of them being accompanied with 
much contusion, that measures are invariably taken ab initio 
to lessen its severity. These consist in the application of 
cooling lotions to the limb and attention to position, elevating 
the fracture-box or foot of the bedstead. When evaporating 
lotions are employed, oiled or rubber cloth should be placed 
upon the pillow to prevent its becoming wet and unpleasant. 
In order to obviate deformity in these fractures when they 
occur at the lower part of the leg, it is highly important to 
keep the foot well forwards, and this is best done by placing 
under the head some layers of carded cotton. 

At the end of five or six weeks, the union is generally 
sufficiently firm to allow of the removal of the limb from the 
box, and a bandage and pasteboard splints, made to fit accu- 
rately the leg by previously soaking them in warm water, are 
applied to its sides. On these becoming hard, the patient is 
permitted to move about. 

In very oblique fractures of the leg, where the pressure 
made by the pillow is not sufficient to prevent the recurrence 
10 



138 



CONTRIBUTIONS TO PRACTICAL SURGERY. 






of deformity after its reduction, permanent extension is kept 
up by means of Desault's splints, as in fractures of the thigh. 

In fractures of the lower end of the fibula, where the foot 
is much drawn outwards, the apparatus of Dupuytren, con- 
sisting of a conical pad to make pressure over the internal 
malleolus, and a single splint applied to the inside of the 
limb, from the upper extremity of the leg to some distance 
beyond the foot, is employed ; but where, as is most generally 
the case, the tendency to a recurrence of the deformity is not 
in a great degree, the apparatus commonly made use of for 
other fractures of the leg, consisting of the fracture-box and 
pillow, so placed as to exert rather more pressure than usual 
upon the outer ankle, is resorted to. These fractures are 
sometimes accompanied by compound luxation of the lower 
end of the tibia. The following instance in which this oc- 
curred, where the lower extremity of the tibia was success- 
fully removed by Dr. Harris, was witnessed by me. 

Barney Short, setat. 32, was admitted on the 21st of June, 
1830, for a compound fracture at the ankle. Upon examina- 
tion, the foot was found to be thrown outwards, and the end 
of the tibia to protrude through the integuments, which em- 
braced it tightly, at the same time that there was a fracture 
of the fibula three inches above the joint. 

Pretty strong efforts were made to reduce the displaced 
bone, which caused the man so much pain, that Dr. H. desisted 
from his attempts, and determined to saw off the projecting 
end of the tibia. 

About an inch and a half was accordingly removed, after 
which the bones were easily reduced and the limb placed in 
a fracture-box and cold applications made to it. Although 
severe inflammation followed the operation, yet the man did 
well, and was discharged on the 13th of October following, 
walking with the aid of a crutch, but with the wound per- 
fectly healed. 

Two years after, Short visited the hospital; his leg was 
perfectly sound, though of course shortened. With a high- 
heeled shoe he walked very well and a great deal — his occu- 
pation being at the time that of a peddler. 



STATISTICS OP FRACTURES AND DISLOCATIONS. 139 

Patella. — In fractures of this bone, the treatment consists 
in the application of a roller from the toes upwards, passed 
around the knee in such a way as to bring the fragments into 
apposition, and applied with a very moderate degree of tight- 
ness. The limb is then extended upon a well-padded splint, 
extending from a little above the heel to the upper part of 
the thigh, and the whole is afterwards placed upon an inclined 
plane composed usually of pillows. 

Clavicle. — For a number of years past, the use of Desault's 
apparatus for fracture of the clavicle has been entirely 
abandoned. As generally put on, the apparatus does not ful- 
fil the indications intended, and when applied tightly and 
properly, so as to keep the fragments in perfect apposition, it 
in most cases produces great difficulty of respiration, or 
severe pain in the arm or chest. Besides this, it soon becomes 
relaxed, is easily deranged, and covers entirely the seat of 
injury, thereby making it impossible to ascertain whether or 
not the reduction remains complete without the removal of a 
part of it. The apparatus used at the hospital consists in a 
pad for the axilla, a ring formed of some soft substance, as a 
roll of muslin or of buckskin, for the shoulder of the sound 
side, and a sling for the elbow made of linen, extending half 
way up the arm, and two-thirds of the way down the forearm. 
To the elbow-piece are attached three strong tapes — one to its 
upper and posterior part, and one to each anterior extremity. 
The following is the mode of applying the apparatus: a pro- 
per pad being selected and fixed in the axilla, by means of 
tapes fastened to its upper ends, and passing over to the sound 
shoulder, the ring or collar is carried up and held on the 
shoulder of the sound side; the sling is then fitted to the 
elbow, and after the fracture is reduced by drawing the arm 
downwards, and pushing the elbow upwards across the chest,, 
the tape on its posterior part is carried over the back and 
firmly tied to the collar on the opposite side. This done, the 
surgeon comes round in front of the patient, and makes fast 
to the collar the tapes attached to the anterior extremity of 
the elbow-piece. These are to be drawn tight enough to 
throw the shoulder sufficiently outwards and upwards to re- 



140 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



move all deformity. The hand is then supported in a sling, 
or by a strip of bandage fastened to the collar. The whole 
apparatus is to be re examined and tightened daily. The 
chief indications in the treatment of fracture of the clavicle 
are perfectly fulfilled by the use of this apparatus ; the pad 
in the axilla throws the shoulder outwards, at the same time 
that the drawing up of the elbow by the linen bag throws it 
upwards and backwards. Besides this it is simple, requires 
no bandaging, and leaves the part injured at all times open 
to inspection. The apparatus, too, can readily be applied in 
females, in whom it is all. important to obviate deformity. 
The apparatus was contrived and introduced into the practice 
of the hospital in 1828, by Dr. Fox, then house-surgeon, since 
which time it has been constantly employed. 

Spine. — The treatment in these cases consists in keeping 
the patient in a state of perfect rest, at the same time that 
pressure is taken off the projecting parts as much as possible 
by the application of pillows and other appropriate means, in 
the careful use of the catheter, and in obviating any symptoms 
of inflammation that may set in by the usual treatment. No 
instance has occurred in the twenty years in which the ope- 
ration for raising depressed portions of the vertebrae has been 
practised. 

Humerus. — In fractures situated at the middle of the bone, 
three or four pasteboard splints are commonly made use of — 
the outer extending from the top of the shoulder to the ex- 
ternal condyle, the inner reaching from the axilla to just 
above the internal condyle, and the anterior one sufficiently 
long to reach to the bend of the arm. The roller is applied, 
as in all other cases, from the fingers up, and the fracture 
being reduced, and the splints fixed as mentioned, is returned 
and fastened over them. The arm may then be bound to the 
body by a broad bandage, or can be left free, supported by a 
sling. In patients who are very restless, the roller soon be- 
comes loose about the forearm and elbow, and necessitates a 
frequent reapplication of it. To prevent, in a measure, this 
almost daily renewal, the use of an angular board splint well 
padded, and extending from the axilla to the hand on the in- 



STATISTICS OF FRACTURES AND DISLOCATIONS. 141 

side of the arm, is sometimes substituted; one or more short 
splints being at the same time applied above the elbow. The 
fragments by this means are held perfectly in place, and the 
angular splint, by holding the forearm at rest, keeps the 
bandage well and evenly applied for a much longer period 
than is otherwise possible. During the cure, the angle of the 
splint should be occasionally changed, in order to prevent 
any degree of stiffness at the elbow. This mode of dressing 
is applicable to fractures below the insertion of the deltoid 
only; for fractures situated high up in the bone it would be 
manifestly improper. 

Elbow. — One of the most common of these, after fractures 
of the inner condyle, is that in which two fractures and three 
fragments are present, the humerus being broken transversely 
just above the condyles, and these last separated longitudi- 
nally. All fractures about this part are very troublesome and 
serious accidents, and to treat them well requires extraordi- 
nary care and attention, whatever method of treatment may 
be made choice of. Two rectangular splints applied to the 
inner and outer sides of the arm, and extending from its 
upper part to the ends of the ringers, are frequently employed 
with us. When these are used, the angles of the splints 
should be frequently changed to prevent deformity and stiff- 
ness of the joint — those first applied being removed after ten 
or twelve days, and replaced by others of an obtuse angle. 
Another method of treatment, which is sometimes pursued 
at our hospital in fractures about this joint with very satis- 
factory results, consists in the application of a single board 
splint applied to the front of the arm. This should be of the 
width and shape of the limb, well padded, and extending 
from the upper part of the arm to the ends of the fingers. At 
first a right angled splint may be used, but at every dressing 
(and after the first few days they should be frequent) it is to 
be changed for a more obtuse angled one, until finally the 
arm can be brought perfectly straight. The obtuse angled 
splints are then recommenced with, and gradually replaced 
by, others less obtuse, until the limb is again brought to a 
right angle. This plan, carefully pursued, will generally pre- 



142 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



vent deformity, at the same time that it is of more easy appli- 
cation, and more effectually hinders the occurrence of anchy- 
losis than the common mode of dressing. The hinged splint, 
in which the angle is regulated at will by a screw, is also 
occasionally employed for similar purposes. 

Forearm. — These accidents are treated by means of a roller 
and two splints, applied in the usual manner. Fractures of 
the lower end of the radius, which, it may be remarked, are 
very frequently mistaken for simple sprains, are treated also 
with two splints; the inside one extending from the upper 
part of the arm beyond the ends of the fingers, while that on 
the outside passes below the knuckles. In these, as in all 
other cases in which a simple fracture communicates with, or 
is in the immediate neighborhood of, the wrist or elbow-joints, 
the dressings should be removed at the end of ten or twelve 
days, and, after the joint is gently exercised, are to be re- 
applied. This should be repeated, at furthest, every second 
day. The same rule should be observed in all cases in which 
the forearm is confined in two long splints, as otherwise great 
rigidity of the wrist-joint occurs, which is annoying to the 
patient, and requires a very long time for its disappearance. 1 

Bibs. — Fractures of the ribs are treated by the application 
of a broad roller to the chest, confining the patient to bed, 
and the usual general treatment, such as abstraction of blood, 
etc., when dyspnoea, pain, or other untoward symptoms arise. 
A large pitch plaster is sometimes used with advantage. 

Cranium. — In cases of simple fractures of the cranium with 
depression of bone, but unaccompanied with symptoms of com- 
pressed brain, the trephine has not been resorted to, while, in 
instances of compound fracture, attended with depressed frag- 
ments, even where no symptoms of compression existed, it has 
been the general practice to remove the portions driven in. 

No separate head is retained for compound fractures of the 
leg or arm, the entries being so made in the books of the in- 
stitution that it is impossible in all cases accurately to ascer- 



1 In later years, Bond's splint, in which the forearm is supported by a 
board applied to its inner surface, while the hand is made so to clasp a block 
as slightly to evert it, has been used very successfully. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 



143 



tain whether the patient was admitted for simple or compound 
fracture, and for the same reason under the heads of fracture 
of the arm and fracture of the leg, are included, respectively, 
those of the forearm, either of one or both bones, as well as 
of the humerus, and one or both bones of the leg. It is to be 
regretted that no record of the period required for the union 
of the different fractures treated has been kept. In all cases 
except a very few where our patients request a discharge, it 
is the custom of the house to retain them for a considerable 
time after union — until the stiffness and debility resulting 
from their injuries and confinement have been so far removed 
as to enable the patients shortly afterwards to resume their 
employments. 

The number of fractures treated during the twenty years 
from 1830 to 1850 was 2208, and their relative frequency will 
be seen in the following table. 





Number. 


Cured. 


Relieved 
or removed 
by friends. 


Died. 




266 

611 

110 

42 

25 

6 

188 

579 

69 

28 

2 

23 

51 

13 

50 

88 

1 

3 

1 

3 

30 
1 


217 

490 

32 

38 

1 

4 

165 

506 

61 

21 

1 

16 

33 

9 

34 

72 

1 

3 

2 

8 
1 


17 

29 

11 

3 

4 
1 

20 

48 
7 
5 

*4 
10 

6 

8 

i 


32 




92 


Fractured cranium 


67 




1 




20 


Fractured sternum 


1 




3 


Fractured arm 


25 


Fractured fingers 


1 


Fractured scapula 


2 


Fractured elbow 


1 


Fractured nose and face 


3 


Fractured jaw 


8 


Fractured pelvis 


4 


Fractured feet and toes 


10 


Fractured ribs 


8 


Fractured astragalus 




Fracture 




Compound fracture knee 


1 
1 


Compound fracture thigh 


21 


Fractured os calcis 










2190 


1715 


174 


301 


Ununited fractures 


18 


11 


5 


2 




i 




2208 


1726 


179 


303 



144 CONTRIBUTIONS TO PRACTICAL SURGERY. 

No instance of artificial joint followed the treatment for 
fracture during the twenty years included in the report, 
all the cases observed there during that period having been 
sent to the institution from distant parts. Of the eighteen 
cases that were received, twelve were cured, two died, one 
was benefited, and four left the house a short time after 
entrance without undergoing any treatment for it. Of the 
fractures included in the above table, many were compound, 
and many complicated by other serious injuries. 

Dislocations. — With the exception of a few of the luxa- 
tions of the shoulder and hip, the cases included in the table 
at page 147 were of recent occurrence, and in all of these 
the bones were reduced without accident of any sort. Two 
out of the four luxated shoulders marked as discharged by 
request, were incurable. One of them existed in the person 
of a young sailor, aged 20, who was admitted December 4, 
1830, with a forward dislocation of the head of the humerus 
of sixty-two days' standing. Some days after his entrance, an 
attempt was made by Dr. Hewson to reduce it by means of 
the pulleys. Great force was used, and the efforts were kept 
up for a long time, but without success. After the lapse of a 
short time, by request of the patient, strong efforts were again 
made to reduce it, and kept up for a considerable time, but 
with no better effect than on the first attempt. 

The other case was a forward luxation of three months' 
standing, which it was found impossible to reduce by any 
proper degree of force. 

Among the cases of dislocation of the shoulder cured, are 
those which had been out twenty-six, forty-five, fifty-three, 
thirty-one, ten, twenty-one, thirty-one, seventy, thirty-four, 
forty-eight, thirty-one, two of twenty-nine, ten, and four days 
respectively. One of the recent dislocations was accompanied by 
a compound fracture of the elbow of the same side, of so severe 
a character that amputation in the middle of the arm was per- 
formed, the luxation being reduced previous to the operation. 

Of 49 dislocated shoulders in which the direction of the 
displacement is noticed, 39 were into the axilla, and in 10 the 
head of the bone was found under the clavicle. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 145 

In one of the luxations, the reduction was followed by in- 
flammation and suppuration about the joint. The patient was 
a stout countryman, aged 25, from Carlisle, and had been 
injured forty-eight days previous to his applying for relief. 
The dislocation was into the axilla. On the 21st of December, 
1840, the pulleys were applied, and extension was made gradu- 
ally and moderately for fifty-five minutes, previous to and 
during which time a solution of tartar emetic was given, and 
a large bleeding resorted to. At the end of the period men- 
tioned, the head of the bone was returned to its socket, all 
deformity disappearing. Two days after the reduction he was 
attacked with inflammation around the orifice made by vene- 
section, which went on to suppuration, and an opening for 
the evacuation of the pus was made on the 28th. The shoulder 
of the dislocated side, which had become swelled and hot 
soon after the reduction, despite the employment of the usual 
means for allaying inflammation, presented on the 30th more 
swelling, and a sensation of deeply-seated pus. On the 31st, 
the fluctuation was more distinct and an opening was now 
made, giving issue to a quantity of healthy pus. After the 
opening of the abscess, the discharge continued till towards 
the middle of February, during which time he suffered from 
an attack of erysipelas, then prevalent in the hospital. After 
this period, the discharge gradually lessened in quantity and 
became thinner. Early in March, an abscess formed at the 
posterior part of the axilla, which was opened and discharged 
freely. By the beginning of April, the abscess had closed, 
and all heat and swelling had left the part. On the 26th of 
the same month he returned home, the head of the bone 
being in the socket, though the parts about the shoulder were 
still much hardened and stiff. 

In another case, which I failed to reduce, the head of the 
bone was in the axilla, and was of ten weeks' standing. The 
patient was fifty years of age, and was admitted into the hos- 
pital June 11th, 1840. He stated the accident to have been 
produced by a fall; that some efforts were made to replace 
the bone immediately after its occurrence by an unprofessional 
person, and that a week before his entrance well-directed and 



146 CONTRIBUTIONS TO PRACTICAL SURGERY. 

long-continued efforts were made by a surgeon to reduce it. 
He was a blacksmith by trade, and, being anxious for a 
further trial to reduce it, had entered the hospital for that 
purpose. All the symptoms of luxation downwards were well 
marked. The head of the bone was high up in the axilla, 
and admitted of very little motion. The dangers to which 
he would be exposed by efforts at reduction having been first 
plainly stated to him, the pulleys were applied, and extension 
and counter-extension, to as great a degree as was judged safe, 
kept up for nearly an hour, at the same time that the muscular 
system was relaxed by bleeding and tartar emetic. At the 
expiration of this time, as the head of the bone had not 
yielded in any degree to the force employed, further efforts 
were desisted from, and he left the house. 

The subject of the reduction of dislocations of long stand- 
ing is one of considerable interest. The class of cases and the 
periods after the injury, in which attempts maybe undertaken 
with any prospect of success, as well as the accidents that 
sometimes follow them, have not as yet received that attention 
which they merit. In the first of the above cases, where the 
patient was young and robust, and the arm admitted of some 
motion, the reduction was accomplished seven weeks after 
the accident, by the employment of a less degree and shorter 
continuance of extensive force than I have repeatedly made 
use of, but was followed by inflammation and suppuration 
about the joint. This accident does not very often occur 
after attempts at replacement of luxated bones, though cases 
have been observed in which it has followed the easy reduction 
of even recent dislocations. In the last case, where the injury 
was of ten weeks' duration, and the patient somewhat advanced 
in life, with the head of the bone drawn high into the axilla, 
we were foiled in our attempts to reduce it, and understood 
that the patient subsequently submitted to a third pulling, 
under the direction of a gentleman of this city, after pre- 
vious division of some of the muscles or tendons about the 
joint, without better success. 

I am well aware that surgeons have always examined into 
the degree of motion existing in an unreduced joint before 



STATISTICS OF FRACTURES AND DISLOCATIONS. 



147 



determining upon the propriety of an attempt at reduction, 
in cases where bones have been long out ; but, nevertheless, 
am disposed to think that we have been accustomed to direct 
our attention too much to the time which has elapsed since 
the receipt of the injury only, without allowing the situation 
of the bone, and the degree of motion, due weight in deter- 
mining the question. Abundant evidence might be adduced 
to show that luxations have often been reduced after the 
limits fixed upon by our best authorities, where the head of 
the bone admits of slight movements, and is not drawn up 
closely into the axilla, and where an opposite state exists they 
are frequently irreducible long before that limit is arrived at. 

General Summary of the Dislocations treated during twenty years, from 

1830 to 1850. 





Number. 


Cured. 


Relieved 
or removed 
by friends. 


Died. 


Dislocated shoulder 


101 

21 

3 

1 

2 
2 

16 
4 

12 
2 
1 
1 
1 
1 
1 
1 
2 
5 


96 

17 

1 

*2 

1 
16 
4 
9 
2 
1 
1 
1 
1 

2 
3 


4 
3 

*3 

'i 


1 


Dislocated hip 


1 


Dislocated astragalus 


2 


Dislocated jaw 


1 


Dislocated ankle 


1 


Dislocated elbow 




Dislocated wrist 




Dislocated clavicle 




Dislocated radius 




Dislocated great toe 




Incomplete dislocation of knee 

Dislocated semilunar cartilage .... 
Dislocation and fracture 




Dislocation 


1 


Compound dislocation of fingers. . 
Compound dislocation of thumb . . 


*2 


Total. 


177 


157 


11 


9 



A case of dislocation with fracture of the astragalus is in- 
cluded in these tables. It was that of Samuel Dobbins, aged 
15, who was admitted July 20th, 1846, with injuries received 
by being caught in the machinery of a mill. Two wounds 
existed on the scalp, he was much contused about the body, 
and the left ankle was severely contused, though the skin was 
not broken, and there was a rounded projection behind the 



148 CONTRIBUTIONS TO PRACTICAL SURGERY. 

external malleolus, with the foot in the natural position. He 
was but partially sensible when admitted, and was feeble, 
with a cool surface. He slowly reacted and became sensible, 
and by the following day the ankle had become much swollen. 
The limb was placed in an easy position on a pillow in an 
elevated fracture-box, and cooling applications made to it. 

On the 24th, though the swelling continued, he complained 
of no pain in it, and a careful examination proved that the 
projection on the outer side of the foot was a portion of the 
astragalus which had been broken off and thrown from its 
socket. It could not be returned by moderate efforts. 

On the 31st a slight discoloration of the skin over and 
around the malleolus was observed. On the 5th of August 
fluctuation was distinctly felt, and pus of an unhealthy cha- 
racter was discharged by an opening made for that purpose. 
By the 9th the discharge had become more healthy, and the 
swelling had abated ; but the youth was exceedingly feeble. 
A nutritious diet, tonics, and porter were allowed. 

ISTo great change took place till the 28th, when sloughing 
occurred about the injury, and erysipelas soon followed, ex- 
tending up to the knee. Previous to this, the displaced piece 
of the astragalus was immovably fixed, but after the inflam- 
mation subsided it became movable, and was so loose by the 
3d of September that it was removed. Upon examination, it 
proved to be that portion of the astragalus which articulates 
with the tibia. A large abscess afterwards formed about the 
middle of the leg which was opened and soon filled up ; the 
wound made by the opening and sloughing over the bone 
closed rapidly, and on the 3d of October he left the hospital, 
walking with a cane and with considerable motion at the 
ankle. 

A case of a similar kind was witnessed by me in 1831, when 
a resident of the institution. It was that of William Sum- 
merill, ostler, aged 30, who was admitted on the 26th of Sep- 
tember, and came under my immediate care under the direction 
of Dr. J. R. Barton. 

An hour previous to admission, while descending a ladder, 
he slipped and fell in such a manner as to throw the entire 



STATISTICS OF FRACTURES AND DISLOCATIONS.' 149 

weight of his body upon the outer part of his left foot. 
Upon examination the foot was found to be turned inwards, 
and nearly immovable. A slight depression existed immedi- 
ately below the lower end of the tibia, and there was a con- 
siderable hard and rounded projection on the outer part of the 
foot, a little below and in front of the extremity of the fibula. 
The skin covering this projection was reddened, but not exco- 
riated. There was no fracture of either bone of the leg. 

These appearances rendered it evident that the injury was 
a dislocation outwards and forwards of the astragalus; and a 
short time after admission efforts were made by Dr. Barton to 
reduce it. This was done, after relaxing in as great a degree 
as possible the muscles of the leg, by fixing the knee and 
having assistants to keep up extension by seizing the heel 
and front part of the foot at the same time that the bone was 
pushed inwards and towards the joint by the surgeon; these 
efforts were continued for a considerable time, but had no 
effect in changing the position of the bone. 

Six hours afterwards, in consultation, attempts were again 
made at reduction, which, not proving more effectual than on 
the first trial, the excision of the displaced bone was deter- 
mined on. 

The patient being properly placed, an incision was made 
through the integuments, parallel with the tendons, com- 
mencing a short distance above the projection on the foot, 
and extending down far enough to expose fairly the astragalus 
and its torn ligament; the bone was then seized with, forceps 
and easily removed after the division of a few ligamentous 
fibres that continued to connect it to the adjoining parts. 
Very little hemorrhage occurred ; two small vessels only 
requiring ligature. 

After removal it was discovered that about one-half of the 
surface which plays in the lower end of the tibia, had been 
fractured, and remained firmly attached to the extremity of 
that bone, and, as it was judged that the efforts necessary to 
remove this would be likely to produce more injury to the 
joint than could arise from allowing it to remain, no attempt 
was made to extract it. 



150 • CONTRIBUTIONS TO PRACTICAL SURGERY. 

The joint being carefully sponged out, the sides of the 
incision were brought accurately together by means of a 
suture and adhesive strips, after which, simple dressings and 
a roller were applied, and the foot, restored to its natural 
position, was placed in a fracture-box. 

Sept. 27th. Had a restless night, having suffered from pain 
in the joint. Pulse good ; skin moist ; no thirst ; has now 
but little pain ; has taken opium freely since the operation, 
which is to be continued. Low diet. 

28th. Passed a good night; is without fever; no pain in 
the foot, which lies comfortably in the fracture-box: dressings 
are moistened by oozing from the wound, but have not been 
disturbed ; bowels confined. Common enema ; opium con- 
tinued; soup. 

29th. Does not complain of limb; rested well; general 
symptoms good; dressings removed; no union; wound sup- 
purating freely. Opium continued ; soft poultice to the part. 

October 1st. Yesterday (30th) a portion of the skin on the 
outer part of the foot was red, and tender to the touch, and 
to-day a small slough, about an inch in diameter, occupies 
that part ; wound, nevertheless, looks well, though the sup- 
puration is more free. Same treatment continued. 

5th. Since last report the discharge has been gradually 
augmenting, and is now profuse. Slough did not increase in 
size, and was not deep ; bowels regular ; pulse more frequent 
and feeble ; tongue clean ; night sweats. Good diet, with 
porter ; opium and poultice continued. 

8^. Both ligatures came away ; suppuration continues free; 
a collection of pus has formed near the internal malleolus, 
for the free discharge of which a counter-opening was made; 
heavy sweats at night ; no diarrhoea ; appetite failing. Sol. 
sulph. quinine; morphia at night. 

By the 15th the discharge of pus had greatly lessened, and 
his general symptoms had improved. 

December 12th. To-day that portion of the astragalus which 
had been suffered to remain attached to the tibia was found 
to be carious and loose, and was removed. Constant pressure 
on the heel has produced ulceration of it. The limb is much 



STATISTICS OP FRACTURES AND DISLOCATIONS. 151 

swollen ; wound has made but little progress towards cicatri- 
zation ; granulations are exuberant and of a light color ; 
secretion of pus still great ; general symptoms good. A 
probe introduced through either opening into the joint, shows 
the surfaces of the adjoining bones to be rough, softened, 
and evidently carious. 

March, 1833. Since the last report (a period of fifteen 
months), various means have been resorted to for the removal 
of the carious portions of bone and cicatrization of the 
wound, but unsuccessfully. At this time the bones of the 
foot and ends of the tibia and fibula are all diseased. The 
patient's general health has suffered severely from the long- 
continued irritation. He has well-marked hectic fever, ac- 
companied by heavy night sweats ; he has also frequent 
attacks of erysipelas in the limb, and diarrhoea. Amputation 
of the leg was now looked upon as the only means of saving 
his life, and was accordingly done on the 27th by Dr. Barton. 

The circular operation was performed, and union by the 
first intention attempted. The stump never took on a good 
appearance, showing no disposition to unite, and discharging 
a thin fetid matter. His diarrhoea returned a few days after 
the performance of the amputation ; his strength failed, and 
he died on the 5th of April. 

Examination of the amputated limb showed that no at- 
tempt at regeneration had been made in the joint ; the bones 
of the tarsus and ends of the tibia and fibula were in a great 
measure deprived of their cartilages, and so much softened, 
as to be readily cut into with a scalpel. The tarsal ends of 
the metatarsal bones were also softened, and the tibia was 
spongy in its whole extent, and remarkably light. 

The records of our science possess but few cases of luxation 
of the astragalus, not complicated with laceration of the 
integuments ; and an examination of those reported show 
that surgeons are at variance in regard to the best mode of 
treatment of them. All agree that efforts should at first be 
made to restore the displaced bone ; but this failing, as in the 
majority of instances it does, where the luxation is complete, 
what course is to be pursued ? Is the bone to be suffered to 



152 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



remain in its new situation, or is it to be removed ? Tf per- 
mitted to remain, violent inflammation of the integuments 
and joint is almost certain to follow, in which event there is 
great danger, from the state of tension the parts are placed 
in, of gangrene occurring and necessitating the amputation of 
the limb if not endangering the life of the patient ; and even 
should, the dangers of inflammation and gangrene be escaped, 
and a natural cure take place, great deformity and lameness 
must necessarily ensue, and the patient will remain more or 
less liable to ulceration of the skin over the projection on the 
outer part of the foot. For these reasons we deem the prac- 
tice pursued by Summerill, of excising the astragalus, where 
the case is uncomplicated by other serious, injury, far prefer- 
able to leaving the cure to nature; and the limb cured by the 
removal of the bone, though shortened and anchylosed, will 
be found both more useful and sightly than the club-foot 
deformity left after a natural cure. 

Desault' reports two cases of this accident ; one he reduced 
without difficulty, and the other he succeeded in replacing 
after enlarging the wound of the capsule. Boyer 2 details one 
case where the bone was left undisturbed ; on the 18th day 
inflammation came on, and terminated in gangrene, when the 
limb was amputated with success. Mr. Gooch 3 relates a case 
of an irreducible luxation of this bone, in which he deemed 
it proper to amputate the limb. Sir A. Cooper 4 gives two 
cases, both irreducible. The first was attended with fracture 
of the tibia at the internal malleolus, and was left to nature; 
"the integuments sloughed, and the wound was a long time 
in healing." The second case was attended with a fracture 
of the fibula a little above the joint, and was also left to 
nature ; the skin sloughed on the 22d day and exposed the 
astragalus. After four weeks the bone became loose and was 
removed, and at the end of five months the patient recovered. 

In September, 1833, I saw a case treated by M. Dupuytren 
at the Hotel Dieu of Paris. Two fruitless efforts were made 
at reduction, but he succeeded in bringing the foot nearly 



1 (Euvres Ohirurgicales, torn. i. 

2 Surgical Works of B. Gooch. 



2 Malad. Chirurgic, torn. iv. 
4 On Dislocations. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 153 

into its natural position. Six weeks afterwards the patient 
could use his limb. A small slough formed over the tumor 
some time after the accident, but separated without opening 
the joint. This case has been published in the 13th volume 
of the Journal Hebdomadaire, where mention is made of two 
other cases treated by the same surgeon. In one of these the 
bone was easily reduced; and, failing in the other, he pro- 
posed its extirpation. This was rejected by the patient, who 
ever after moved about with "pain and difficulty," the foot 
being greatly turned inwards. In the Archives Generates for 
December, 1833, a fourth case of the same surgeon is alluded 
to that was left to nature ; gangrene followed, and the man 
was cured by amputation of the leg. In the same journal a 
case of Professor Nanula of Naples is given, where the prac- 
tice pursued by Desault of enlarging the wound in the capsule 
was followed, and the patient recovered with a good limb. 

Dr. J. E. Barton informed me that he had seen two ex- 
amples of simple dislocation of the astragalus at the Pennsyl- 
vania Hospital. One of these was in 1816, and being irre- 
ducible, was not interfered with. Inflammation came on 
after a short time, when the integuments sloughed and part 
of the astragalus was exposed; this, however, was soon 
covered by healthy granulations, and cicatrized. At the end 
of five months the patient walked and had good use of the 
joint, though great deformity of the foo*t existed, and he con- 
tinued to be subject to ulceration of the newly formed skin 
on its outer part. In the other case, the care of which was 
also left to nature, gangrene took place soon after the accident, 
and the man died. 

Compound, though more frequent than simple, dislocations 
of the astragalus, are nevertheless sufficiently rare to make 
their notice a matter of some interest. Formerly they were 
thought to require immediate amputation, but a sufficient 
number of observations is now collected conclusively to 
prove that the limb may be saved, though it has generally 
been thought necessary to remove the bone. Indeed, in the 
majority of these cases, this is so much detached from the 
adjacent parts as to be unable to support its vitality, and will, 
11 



154 CONTRIBUTIONS TO PRACTICAL SURGERY. 

if returned, produce all the bad effects of a foreign body 
introduced into a joint. 

In asserting that compound are more frequent than simple 
luxations of the astragalus, I am well aware that it is con- 
trary to the opinion expressed by our highest authority, Sir 
Astley Cooper. At page 327 of his great work, he says, 
"A simple dislocation of the astragalus sometimes, though 
rarely, occurs; a compound luxation is much more rare." 
The grounds for this opinion, which is likewise that of most 
surgeons, are not stated ; but that it was not the result of his 
own experience, is shown by his reporting five cases of the 
accident attended with more or less laceration of the integu- 
ments, while he gives but two of its simple displacement. A 
comparatively large number of examples of the compound 
dislocation of this bone may be found scattered through 
surgical writings. Hildanus, 1 the first author who speaks 
with precision of these luxations, gives an instance in which 
it occurred and the patient recovered after the extirpation of 
the bone. Boyer 2 cites five cases, all terminating successfully. 
Desault 3 and Hey 4 each report three examples of the accident, 
in all but one of which a cure had taken place. Sir A. 
Cooper, as just, stated, mentions five cases occurring either in 
his own practice or that of his friends ; in one of these the 
limb was amputated, and in another the bone was reduced, 
and all terminated successfully. M. Fallot 5 has given a case 
attended with fracture of the surfaces articulating with the 
scaphoid and calcaneum, in which excision was performed 
with success. MM. Arnal and Velpeau 6 have recorded each a 
case terminating fatally ; one fifty-two and the other four days 
after its removal. 

In our own country several examples of the accident have 
been observed. The late Professor Wistar removed the 
astragalus in a case of compound dislocation, and the patient 
was cured with some motion at the joint. Drs. Stevens 7 and 

1 Opera. Cent, ii., obs. 67. 2 Maladies Chirurg., torn. iv. 

3 (Eiwres Cbirurgicales, torn. i. * Practical Observations. 

5 Journal des Progres, tom. i. 

6 Journ. Hebdomadaire, tomes i. and xiii. 

7 N. Y. Med. and Pbys. Journal, No. 20. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 155 

Grillespie 1 have recorded instances where the same practice 
was adopted with happy results; and Dr. Beatty has given an 
interesting case in which a cure followed, though the bone was 
preserved. 2 

I have seen, at the Pennsylvania Hospital, a case where the 
astragalus was thrown completely out from the limb; the 
following brief statement of which is taken, from the note- 
book of my deceased friend, Dr. Hammersley, at that time 
one of the resident physicians. 

The patient, Isaac Lyon, setat. 22, was admitted on the 
afternoon of July 20th, 1829. He was of intemperate habits, 
and had received his injury a short time previous to being 
brought to the hospital, by the falling of a pile of boards 
upon his leg. The ankle-joint was laid open obliquely on its 
outer side for about four inches, and the external malleolus 
exposed. A bone that had been picked out of the soft earth 
upon which he had been lying, was handed to the doctor by 
a person who accompanied him, and proved to be the astraga- 
lus, with one of its edges broken off. There was no hemor- 
rhage from vessels of any size, there being only a general 
oozing from the part, and no other injury was received. The 
attending surgeon, Dr. Barton, saw the case soon after admis- 
sion, and directed the sides of the wound to be brought loosely 
together with adhesive strips, and the limb to be placed in a 
proper position in a fracture-box, with just pressure enough 
on its sides to steady it. The patient did not complain of 
much pain, but was kept under the influence of anodynes. 

On the third day enormous swelling of the limb, and a 
crackling sensation upon pressure over the tibia existed ; the 
whole leg and inside of the thigh were of a copper color, and 
some bloody vesicles had appeared around the ankle and 
upon the inside of the leg ; countenance shrunken ; pulse 140, 
and wound discharging a thin ill-conditioned pus. The treat- 
ment consisted in the free use of opium, stimuli, and nourish- 
ing soups ; poultice to wound and lead-water to the limb. 

On the morning of the fifth day he was unable to open his 

1 Amer. Journal, Aug. 1833. 

2 Phila. Journ. of the Med. and Phys. Sciences, vol. v., N. S., 1827. 



156 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



mouth freely, and his head was at times thrown back forcibly 
upon his pillow. These tetanic symptoms increased in vio- 
lence, and towards night became general ; and he lingered on 
in the greatest agony till the evening of the 27th. 

A case of compound dislocation of the first upon the second 
phalanx of the thumb, in which reduction was impossible until 
after resection of the head of the first phalanx, came under 
notice. The patient was a powerful drayman, aged 28, who, 
while engaged in unhitching his horse, had the end of his 
left thumb accidentally entangled in a link of the drawing 
chain, when the horse, starting suddenly, dragged him some 
distance and produced the accident. He was brought to the 
hospital late in the evening of February 17th, a couple of hours 
after its occurrence, when well-directed efforts were unsuc- 
cessfully made to reduce it, the clove hitch being attached to 
the extremity, after a failure with the hand alone. On the 
following morning, I found the head of the first phalanx pro- 
truding inwards through a wound which embraced more than 
one-half of the circumference of the finger; another effort at 
reduction was now attempted by bending the luxated. bone 
and endeavoring to push its projecting head over that of the 
adjoining bone, but, failing in this, I determined to remove 
the protruding extremity, which was done and the parts then 
easily replaced. The edges of the wound were drawn to- 
gether with narrow strips of adhesive plaster and the part 
covered with dry lint, the hand and forearm being secured 
upon a splint. After the third day, the dressings were daily 
made, the part being only covered with simple ointment. No 
unpleasant symptoms followed. He was discharged March 
23d, and a month afterwards he called at the hospital, at which 
time he had good use of the thumb with some motion at the 
point of injury. 

The difficulty of reduction in cases of simple luxations of 
the phalangeal articulations, even when the patient is seen 
soon after the accident has occurred, is well known, and the 
same difficulty exists in reducing and retaining in place com- 
pound injuries of this class. So hard is the reduction to 
effect, that it is asserted upon the authority of Bromfield, that 



STATISTICS OF FRACTURES AND DISLOCATIONS. 157 

the extending force has been increased to such a degree as to 
tear off the second joint in efforts to reduce the first. In 
compound luxations of the thumb, when found irreducible 
upon the application of a moderate degree of force, I believe 
the best practice to be that which was pursued in the above 
case, viz., to saw off the end of the projecting bone. If the 
wound be large, and this be not done, observation shows that, 
even when the part can be reduced, the dislocated end will in 
the majority of cases become displaced, as the inflammation 
necessarily following it prevents the application of a sufficient 
degree of force by bandages and splints to retain it in its 
natural position. One case of this kind I have myself wit- 
nessed, and another instance which occurred in Gruy's Hospital 
has been published, where, although the phalanx was readily 
reduced immediately after the accident, so much inflammation 
and constitutional disturbance occurred as to make it neces- 
sary to remove the splints which had been applied, and re- 
sort to cataplasms ; the patient being ultimately cured, after 
entire loss of the first, and exfoliation of the extremity of the 
second phalanx. Resection of the phalangeal extremity is 
the practice recommended by Sir A. Cooper in compound 
dislocations of these parts, where difficulty is experienced 
in their reduction, and has often been done with good suc- 
cess. Grooch states that he sawed off the head of the sec- 
ond bone of the thumb, and that a new joint afterwards 
formed. In two instances where the head of the metacarpal 
bone of the thumb was dislocated towards the palm accom- 
panied with wound, and reduction was difficult, the protrud- 
ing parts were successfully sawn off by Mr. Evans. Bobe, 
Wardrop, and Roux have all been successful in like cases. 
The bad effects resulting from these injuries where the head 
of the bone is replaced, and which seem to be at least in part 
owing to the force necessarily made use of, and the state of 
tension afterwards kept up in the surrounding soft parts by 
its return, have been often noticed. An instance came under 
my care, in which high inflammation and tetanus ensued 
upon the injury, where this practice was pursued; and Mr. S. 
Cooper reduced a case at the North London Hospital, which 



158 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



was followed by severe inflammation, terminating in death a 
week after the accident. 

One of the dislocations of the humerus was accompanied 
with a fracture of the neck of the bone, and was happily 
reduced by the resident, Dr. Edward Hartshorne, who pub- 
lished an account of it in the Medical Examiner for 1842. 
The patient was a young circus rider, who had been injured 
by a severe blow from a horse one hour before admission. 
The head of the bone was thrown forwards under the clavicle, 
and was reduced without difficulty by manipulation with the 
hand, while the patient was feeble and relaxed, and the frac- 
ture afterwards treated in the usual way, with a good result. 
Another instance of this rare accident presented itself in my 
service in 1853, and, though not included in the tables, I have 
thought it might be of interest to give it a place here. 

The patient, aged 32, was admitted on the 31st of Octo- 
ber. He was under the effects of liquor, and it was stated 
that he had fallen down a flight of stairs. On examination, 
the soft parts around the left shoulder were found to be very 
much contused, swollen, and discolored by effusion of blood ; 
the extremity was readily movable in any direction, but the 
slightest motion produced great pain. No perceptible de- 
pression was noticed below the acromion ; the elbow could 
be brought close to the side without force, and, on raising the 
arm and moving it for the purpose of examination, the grating 
of a fracture was felt. 

The presence of these symptoms led to the belief that a 
fracture of the neck of the humerus existed, and the case was 
treated by means of a pad in the axilla, with a pasteboard 
splint moulded to the shoulder on the outside of the arm, and 
bound to the body with the forearm supported by a sling. 

This treatment was continued till the 26th of November, 
the dressing being occasionally changed. On their removal 
at the last-mentioned date, the swelling having by this time 
almost entirely disappeared, it was discovered that the head 
of the bone had been thrown from its socket into the axilla. 
At the first glance I thought that my original diagnosis had 
been incorrect, and that, in fact, I had mistaken, and had been 



STATISTICS OP FRACTURES AND DISLOCATIONS. 159 

treating a dislocation for a fracture; but, upon closer exami- 
nation, it proved that such was not the case, but that both a 
fracture and dislocation existed. 

The appearances presented by the parts at this time were 
as follows : — 

To the eye there was evidently a slight vacuity immediately 
below the acromion process, though there was not that deep 
depression which exists in uncomplicated luxation. On rotat- 
ing the arm, the broken shaft of the humerus was perceived 
to move under the acromion at the same time that the rounded 
head of the bone could be easily felt in the axilla, and the 
distance of this fragment from the upper end of the shaft, 
which partially occupied the glenoid cavity, was, as nearly 
as could be ascertained, from two to two and a half inches. 
The shoulder was not firmly fixed as is commonly seen in 
luxation, particularly when the member has been kept quiet, 
as was the case under examination ; but, on the contrary, 
was easily movable, and when the patient stood erect, the 
elbow come in contact with the side of the chest. In order 
to prevent any mistake as to the nature of the accident, I re- 
quested my colleagues in the hospital to visit the case, and, 
after careful separate examinations, they all agreed as to its 
being one such as I have mentioned, viz., of fracture of the 
neck of the humerus conjoined with a displacement of its 
head into the axilla. 

In consequence of the comparatively good use of the limb, 
which the patient seemed likely to attain, and the slight 
probability there was of the head of the bone ever being 
replaced, together with the risk of giving rise to severe in- 
flammation about the joint, and consequent firm anchylosis; 
if any attempt at reduction were tried, it was decided that no 
efforts to replace it should be made. Gentle frictions to the 
part, with passive motion to the shoulder, after all traces of 
the great contusion and consequent inflammation which at- 
tended upon it had been subdued by a state of rest, was the 
treatment afterwards resorted to, and the patient was dis- 
charged on the 1st of January, with a strong and useful ex- 
tremity, but with inability to elevate the arm beyond an 



160 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



obtuse angle from the body. The dislocation of the head of 
the humerus which accompanied the fracture of the neck of 
the bone, in the above case, it will be observed, was not at 
first detected, although the seat of injury was carefully ex- 
amined. The accompanying swelling and contusion of the 
soft parts, the distinct crepitus of a fracture felt upon hand- 
ling the limb, and the other marked symptoms of that acci- 
dent which it presented, together with the absence of the 
ordinary marked ones of luxation, viz., the fixity of the 
extremity, the hollow at the extremity below the acromion, 
and the ease with which the elbow was brought to the side 
of the body, all caused it to be overlooked. 

The difficulty of diagnosis, in connection with the great 
rarity of the injur}?-, alone makes the above case worthy of 
notice ; but, in addition to this, the proper plan of treatment 
to be pursued in these accidents, supposing the diagnosis to be 
made out, does not seem to be well determined by surgeons. 

In the treatises on injuries of the bones, of Sue, Petit, 
Boyer, and Smith of Dublin, no mention is made of luxation 
accompanied with fracture of the neck of the humerus, and 
but few cases of it are to be found detailed in our surgical 
records. 

Delpeoh 1 furnishes an accurate account of a dissection of 
this kind, which was observed by M. Houzelot, but it had 
not been ascertained during life. Dupuytren has reported a 
single case which he saw at the Hotel Dieu, which was not 
reduced. In 1832, an instance of it was witnessed in the ser- 
vice of Mr. Earle, of London, which was replaced by his 
dresser a short time after the accident had occurred, and two 
cases are to be found very accurately described by Peyrani, 2 
neither of which were reduced. In the last edition of Sir 
Astley Cooper's treatise on Fractures and Dislocations of the 
Joints, but five cases of a similar nature are noticed. Of these, 
the character of the accident was not discovered in three of 
them, until revealed by post-mortem examinations. In a 



1 Cliirurgie Clinique, torn. i. p. 241. 

2 Joiirn. de Cliirurgie, torn. iv. p. 180. 



STATISTICS OF FRACTURES AND DISLOCATIONS. 161 

fourth, the fracture was comminuted, and no attempts at re- 
duction were made, and the fifth, which was an injury of six 
weeks' standing, and observed at Guy's Hospital, in 1834:, by 
Sir Astley in conjunction with Mr. Key, was mistaken for an 
ordinary luxation, and the fracture was not suspected till after 
the pulleys had been applied, when, its true nature becoming 
apparent, all further efforts to reduce it were desisted from. 
M. Eichet reduced a dislocated shoulder accompanied with a 
fracture of its neck, by holding firmly the acromion, and 
pushing the head of the bone outwards and upwards with the 
fingers. 

In nineteen cases of luxation with fracture of the humerus 
collected by Malgaigne 1 the luxation was overlooked in five, 
and he adds, that he himself erred in his diagnosis in another 
case. In two instances of dislocation of the humerus with 
fracture of its surgical neck seen by Dr. J. Mason Warren, 2 
f while the muscles were still relaxed, and before the patient 
had recovered from the depressing influence of the shock, it 
was found possible to effect reduction by making extension of 
the shaft of the bone, at the same time working the separated 
head into its socket by firm pressure with the thumbs." 

In regard to the treatment in these cases, I have stated that 
surgeons are not well agreed. Delpech after inspecting the 
parts in the patient of Houzelot, reasons upon it, and con- 
cludes that the reduction of the bone in these accidents is 
impossible. Sir Astley Cooper 3 thus expresses himself : "Ex- 
tension is of no further use than to bring the broken shaft of 
the os humeri into the glenoid cavity, where it forms a useful 
articulation ; but no extension however violent disturbs the 
broken head of the bone, for no proper force could bring it 
into the glenoid cavity of the scapula." "Let the surgeon do 
what he will, the head of the bone will probably remain in 
the axilla, and the upper motions of the arm will be in a con- 
siderable degree lost." Dupuytren says: 4 "When luxation 
is accompanied with fracture of the surgical neck, art and 

1 Traite des Fractures et des Luxations, torn. ii. p. 203. 

2 Surgical Observations, p. 352. 3 Loc. cit., Lond., 1842, p. 427. 
4 Lecons Orales, torn. iii. p. 116. 



162 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



ill 



'i 



nature can do almost nothing." We have seen, however, that 
in some of the instances I have alluded to, success has followed 
the efforts made to thrust back the head of the bone into the 
glenoid cavity, and these should lead us, I think, to make 
some efforts to accomplish it in all cases when seen early, 
though, for the reasons already mentioned, I should myself 
be disinclined to attempt it, except when it is very recent, and 
then by no other force than such as can be exerted by the 
pressure of the hand. 

A case of true dislocation of the fifth from the sixth cer- 
vical vertebrse, unattended by any fracture, is included in the 
above tables, an accident of such rare occurrence, that it is 
deemed worthy of record. The following are its details: — 

Thomas Lee, aged 30, was admitted early on the morning 
of September 9, 1831. At 11 o'clock on the previous night, 
while in a state of intoxication, he had been thrown headlong 
against the curbstone from a gig that he was driving along 
at a furious rate. There was complete paralysis of the lower 
extremities, chest, and lower half of the trunk. He complain- 
ed of great pain over the lower cervical vertebrae; but so 
much swelling and ecchymosis existed at this part, that the 
state of the spinal column could not be satisfactorily ascer- 
tained. When placed in an erect position he cried out from 
pain, unless his forehead was firmly supported; and, when 
laid on his back, his head was seen to be thrown a little for- 
wards, and pushed down upon his chest. The hands and 
arms retained their sensibility, but he was unable to double 
his fist, or seize anything firmly. His respiration was hurried, 
difficult, and performed entirely by the diaphragm; he com- 
plained incessantly of being unable " to breathe properly.'' 
Priapism existed, and continued constant till the period of 
his death. From the existence of the above symptoms, the 
case was looked upon as one of fracture, with consequent 
luxation of the lower cervical vertebras. He was placed on 
his back, with the head and shoulders slightly elevated, had 
his bladder, which was distended, emptied by the catheter; 
and, as his pulse was full, he was bled moderately. By 10 
A.M. his sufferings had become so great, that Dr. Barton, the 



STATISTICS OF FRACTURES AND DISLOCATIONS. 163 

surgeon in attendance, deemed it proper to make some attempt 
to relieve them, by cautiously making extension and counter- 
extension. The extension was made by means of a handker- 
chief passed under the chin, the ends of which were tied 
firmly to the head of the bedstead, and the counter-extension 
was kept up by securing the ankles with a broad bandage, 
and fastening it to the foot-board. The patient expressed 
himself as being decidedly easier after the extension was made. 
On visiting him on the morning of the 11th, I found him 
without pain, and with no apparent change in his symptoms. 
His position was in no way changed ; and, while in the room 
engaged with another patient a few feet distant, my attention 
was directed by the nurse to Lee, and on approaching him I 
found him dead. 

Autopsy. — A considerable effusion of blood was found in 
the cellular tissue beneath the skin, as well as between the 
muscles on the back part of the neck. The yellow ligaments 
and the ligamentous fibres, holding together the oblique pro- 
cesses, were ruptured, and the fifth cervical vertebra was 
thrown forwards upon the sixth. Examined in front, the 
vertebral ligaments were found also to be ruptured, and the 
inter- vertebral substance torn up, so that the body of the fifth 
was completely separated from, and projected over, the sixth. 
Accurate examination, after the removal of the upper part 
of the, spinal column, proved that no fracture existed, and 
that the injury consisted in a simple displacement of both 
body and processes of the vertebrae. The examination was 
made twenty-eight hours after death, but, owing to the heat 
of the weather, putrefaction had considerably advanced, and 
the spinal cord, the coverings of which were uninjured, was 
so much softened in its whole extent, that its state at the 
point of injury could not be determined. 



164 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



ON COMPOUND FRACTURES. 



Though wanting in the charm of novelty, the subject of 
compound fractures is one of much practical interest to the 
surgeon, and involves the consideration of so many of the 
fundamental principles of our science, that but few will be 
found to question its claim to careful study. The variety and 
frequent occurrence of these accidents, the serious complica- 
tions which they oftentimes present, the violent constitutional 
symptoms to which they may give rise, and the importance of 
their proper treatment, not only to the patient, but to the last- 
ing reputation of the practitioner, added to the necessity of 
often determining speedily one of the most difficult and deli- 
cate questions which the surgeon is ever called upon to decide, 
viz., whether a limb must be sacrificed in an attempt to save 
life, or whether the injury is one which will allow of a reasona- 
ble hope of recovery without amputation, all make them worthy 
of oft-repeated consideration. 

The wound in cases of compound fractures is variously pro- 
duced : sometimes it is made by the action of the body causing 
the fracture, as where the wheel of a heavy carriage passes 
over a limb ; in other instances the bone is first broken, and 
the extremity of one of the fragments, generally the upper, is 
pushed through the soft parts, either in consequence of some 
exertion made by the patient after the injury, or by the in- 
voluntary contraction of the muscles; and in some cases the 
fracture becomes compound only by the process of ulceration, 
the formation of an abscess, or by the separation of sloughs, 
resulting from the severe injury the soft parts have met with. 
In the first of these classes the wound is generally large and 
accompanied with great laceration, the bone being often 
comminuted, and the case altogether one of the most serious 
kind ; but in the second class the external injury is mostly of 



COMPOUND FRACTURES. 165 

small extent, and no other parts are injured than those with 
which the bone comes in contact — union of the wound by the 
first intention frequently follows, and, even if this desirable 
event is not obtained, it is soon covered by granulations 
which speedily cicatrize. 

In compound fractures, the age, habits, and constitution of 
the patient, the season of the year, the seat of injury, the mode 
in which the accident has happened, and the degree of violence 
done to the soft parts, have all to be taken into consideration 
before a well grounded opinion of its probable result can be 
come at ; and these subjects, in the order in which they are 
mentioned, I shall now consider. 

Age, habits, and constitution. — "When occurring in advanced 
age, these accidents are always of a most serious nature, and 
this less from fear of the reparative process being deficient, 
than from the fact that patients of this class bear confinement 
to bed badly, being much more exposed thereby to sloughing, 
passive congestions, and internal inflammations than younger 
persons. As after all other injuries, free livers, those of 
broken-down constitutions, and intemperate persons are in 
more peril from them than individuals of an opposite class; 
and in the latter the danger of the occurrence of delirium 
tremens is always great, and when it occurs in many cases 
proves fatal. 

Season. — The degree of heat exerts considerable influence 
upon patients suffering from these injuries, the constitution 
bearing up against them better in temperate or cold weather, 
than during the excessive heats of summer. The marked 
deleterious influence of our hot weather upon patients so situ- 
ated has been noticed by all practitioners ; at such times the 
appetite soon gives way, the strength fails, diarrhoea and 
hectic symptoms supervene, and the patient sinks much sooner 
than at other seasons. 

Mode in which the accident has happened ; seat of injury. — A 
compound fracture produced by force applied directly to the 
seat of injury is always a more severe accident than when the 
wound results from the end of the bone being driven through 
the soft parts. When seated in the immediate vicinity of a 



166 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



large joint, the injury is more serious than when occurring 
near the central part of a bone, there being then considerable 
risk of the neighboring articulation being opened by the ex- 
tension of the inflammation consequent upon the injury; the 
difficulty of retaining the fractured parts in apposition after 
reduction is also generally greater when near to a joint. In 
making a prognosis, too, it is of importance to consider the 
limb affected, those of the upper extremity being less danger- 
ous than of the lower, and as a general rule it may be stated 
that the nearer the fracture be to the trunk, the greater the 
risk incurred by the patient. In the country, or in private 
practice, the chances of saving a limb in these accidents is 
always greater than in large cities or in hospitals. In civil 
hospital practice, compound fractures of the arm and forearm 
generally do well; in the leg, under the same circumstances, 
where an attempt is judged proper to save the limb, the acci- 
dent is more serious, and a number must either suffer second- 
ary amputation or die, and in the femur the majority of adults 
will not survive them. Of fifteen cases of compound fractured 
femur treated in the Pennsylvania Hospital between the years 
1830 and 1840, four were in children below thirteen years of 
age. In one of these (setat. 6) the wound healed kindly, and 
no bad symptoms followed ; in another case (aetat. 7) the 
patient was carried home by his parents and recovered ; in a 
third (setat. 11) the patient died; and the last (setat. 12) re- 
covered with a good limb. Of the eleven cases above thirteen 
years of age, seven died within two weeks after the receipt of 
their injuries ; an eighth (setat. 18) lived three months, and died 
of metastatic abscess ; a ninth (setat. 56) died at the end of 
eleven months of chronic diarrhoea, bony union at the time 
being perfectly firm, though the wound had not closed ; and 
the other two cases (setat. 21 and 15) recovered with good 
limbs, though in the first case not till after twenty-three 
months, and the removal of a necrosed portion of bone six 
inches in length. 

With the exception of compound fractures produced by 
machinery and railroad accidents, those from gunshot are more 
dangerous than such as are met with in civil practice. In the 



COMPOUND FRACTURES. 167 

leg, where both bones are comminuted, they generally require 
amputation, and, in the middle or lower parts of the thigh, un- 
til of late years this indication was thought to be almost im- 
perative, such accidents in this bone being attended with a 
very great degree of danger. Of eight cases treated in Holland 
by Mr. S. Cooper, seven of which were not amputated, only 
one recovered, and that patient retained an useless limb. On 
a review of the cases seen by him during the Peninsular war, 
Mr. Guthrie found that not more than one-sixth recovered so 
as to have useful limbs, two-thirds of the whole died, whether 
amputation was performed or not, and the limbs of the remain- 
ing sixth were not only useless, but a constant source of un- 
easiness to them for the remainder of their lives; and Hennen, 
one of the best of our older authorities in all matters of mili- 
tary surgery, asserts that, without having made any accurate 
calculations, he is strongly inclined to assume Mr. Guthrie's 
estimate as correct, " even including the cases of officers who 
are not subjected to the risks encountered in crowded hos- 
pitals. In these situations," says he, "the cases which I have 
witnessed have, on some occasions, been deplorable. Not a 
single case has done well where amputation was deferred, and 
even where it has been performed two out of three have died. 
In other instances, the losses have not been so severe, but I 
have never known a larger proportion saved than that assigned 
by Mr. Guthrie." 1 The testimony of the French army surgeons 
strongly corroborates that which we have just given. Percy 
states that scarcely two in ten of such cases recover. M. 
Eibes, who has never seen a single cure, gives ten examples 
which despite of every possible attention proved fatal, and 
says, that, out of four thousand individuals at the Hotel des 
Invalides, there was but one who had been cured after this 
injury. In 1815 Mr. Yvan showed two to him, in both of 
whom fistulous openings leading to the bone existed, and 
who ultimately died of affections resulting from their acci- 
dents. 2 Dupuytren, when giving the results of his long ex- 

1 Principles, 3d edit., p. 110. London, 1829. 

2 Gazette Medicale, 1831, p. 101. 



168 CONTRIBUTIONS TO PRACTICAL SURGERY. 

perience in compound fractures from gun shot, says, "On one 
point mj opinion is unchangeable. In rejecting amputation 
in them more lives are lost than limbs saved." 1 

Gases demanding immediate amputation. — The first question 
which arises in the treatment of compound fractures of a 
severe kind is to determine whether or not the sacrifice of 
the limb by amputation be necessary. For the determination 
of this point, it is difficult to lay down any precise and fixed 
rules, as every instance offers something peculiar to itself, 
and all that can be done to aid in determining this highly 
important question is to make known the principles which 
should guide us in a general way, and in urging the propriety 
of invariably delaying the operation whenever a reasonable 
doubt as to its necessity arises. The age, constitution, and 
habits of the patient must be considered, as also the degree of 
care and attention which he may be able to command during 
the treatment. Amputation may be proper after a compound 
fracture in an elderly person, or one of enfeebled constitution, 
or of intemperate habits, or in a patient who is to be treated 
in a crowded hospital, or where any considerable trans- 
portation from the place where the injury was received be- 
comes necessary, when the same kind of injury would not 
demand it in a young subject, or one of good constitution 
and habits, or in an individual living in the country, or placed 
in a pure and uncontaminated atmosphere. Authorities of the 
present day are generally fully agreed upon the necessity of 
amputation in the following cases: — 

1st. Where the bone is comminuted, and the soft parts so 
much contused, lacerated, or destroyed as to make it evident 
that gangrene must follow. 

2d. Where the bone is fractured and a portion of the limb 
torn off by machinery, the bursting of a gun, a cannon shot, 
or the passage over the part of a railroad car. 

3d. Where the laceration of the soft parts around the 
fracture is very extensive or extending into a large joint, 
even though the bone be not comminuted. 

1 Traite des Blessures par Armes de Guerre, torn. i. p. 465. Paris, 1834. 



COMPOUND FRACTURES. 169 

4th. Where the fracture, though accompanied with but 
little laceration, extends through the head of a bone into a 
large joint, as the knee or shoulder. 

5th. Where the bone .is fractured in more that one point 
and accompanied with great laceration and contusion of the 
surrounding parts, or in cases where the bone is extensively 
exposed with the soft part separated from it, especially if 
the fracture be in the neighborhood of an important arti- 
culation, and has been produced by the application of direct 
force. 

6th. In cases where the injury is not so extensive as in the 
instances mentioned, but is accompained with the division of 
the principal artery and nerves, for though neither the divi- 
sion of the vessel, the laceration, nor the fracture may alone 
justify the removal'of the limb, yet the whole together will 
frequently make it necessary. Primary hemorrhage alone 
can rarely, if ever, require it. Where no other indication for 
it is present, the ends of the vessel should be secured at the 
point of injury, or if this be impossible or inexpedient, the 
main trunk above it. In all of these cases great danger to 
life arises from the violence of the reaction, the sloughing, 
the profuse suppurations, and secondary hemorrhages (even 
supposing mortification should not occur) that necessarily 
must take place after injuries such as have been mentioned ; 
and the removal of the injured part by amputation, and con- 
sequent substitution of a clean wound for an extensively 
lacerated and contused one, evidently offer a better chance of 
life to the sufferer. 

The operation of amputation however, it should be recol- 
lected, is of itself always attended with danger, and this varies 
in degree according to the part which is removed ; am- 
putations of the lower being more dangerous than those of 
the upper extremity, and the danger of the operation increas- 
ing the nearer to the trunk it be performed. 

The great mortality following the operation of amputation 
deserves to be glanced at in making up an opinion as to the 
propriety of attempting to save any case of compound frac- 
ture, since it by no means follows, as many seem to think, 
12 



170 CONTRIBUTIONS TO PRACTICAL SURGERY. 

where these accidents terminate fatally in our attempts to 
save them, that life would have been preserved had the ope- 
ration been done, and is another cogent reason for giving to 
the patient the benefit of even the .slightest rational doubt 
in determining upon the question of amputation. 

The remarks here made in regard to efforts to save limbs 
do not however apply to military practice. Hennen lays it 
down as a rule, that "the sum of human misery would be 
most materially lessened by permitting no ambiguous case 
to be subjected to the trial of preserving the limb ; consti- 
tution, convenience for treatment, and local circumstances 
having their full weight in the decision," and his rule to 
operate in such cases is, I think, received and acted upon 
by most of the experienced army surgeons of our period. 

Period for amputating. — The necessity of amputation being 
recognized, it becomes a question at what period the operation 
should be done. Upon this point great difference of opinion 
has existed among surgeons, and much attention has been 
bestowed upon it ever since the period that the question was 
agitated by the French Academy of Surgery, one set of 
practitioners with Boucher at their head insisting upon the 
advantages to be derived from the immediate removal of the 
limb after severe injuries, while others with Faure advocated 
the propriety of postponing the operation till some days have 
elapsed after the receipt of the injury. The strongest advo- 
cates for immediate amputation, both in the last and present 
centuries, have been among military surgeons, and a careful 
examination of the facts adduced by them in support of their 
views must, I think, convince the most skeptical of the pro- 
priety, or rather necessity, for the performance of immediate 
amputation after compound fractures, or other severe injuries 
of the extremities pro*duced by gunshot, when occurring in 
camps or on the field of battle. 

In some compound fractures about the joints when from 
gunshot, the necessity of amputation may be avoided by re- 
section of the articular ends. This procedure is particularly 
applicable to the shoulder, though it has been employed in 
the hip and other joints. The propriety of resecting the head 



COMPOUND FRACTURES. 171 

of the bone in cases of shattered os humeri has been much 
insisted on by Larrey. During the campaign of Egypt, he 
practised it in ten instances, thereby obviating the necessity 
for amputation, and his statements of the benefits resulting 
from it have since been confirmed by later writers. 

The operation, as done by Larrey, consists in exposing the 
head of the bone by an incision made in the centre of the 
deltoid muscle, parallel with its fibres, separating it from its 
attachments, and removing the whole of the fragments. The 
arm is then to be carefully supported, and fixed by means of 
an appropriate sling. Of the ten cases mentioned, one died 
of hospital fever, two of scurvy, a fourth after recovery, of 
the plague, and the remainder returned to France in good 
health, the humerus becoming anchylosed to the scapula in 
some of them, and in others an artificial joint having formed 
that admitted of good motion. 1 The cases to which the prac- 
tice is applicable are those unaccompanied by injury to the 
axillary vessels, or principal tendons about the joint, and 
where the laceration of the soft parts is limited to the deltoid 
muscle and not in an extreme degree. 

Many, however, believe that simple enlargement of the 
wound, and removal of all splinters from it, are often alone 
sufficient and commonly the better practice. Dupuytren 2 held 
this opinion, and Dr. Mann, 3 an experienced surgeon of our 
army during the war with Great Britain, asserts, that when 
the general health is good, the limb can generally be saved by 
a careful removal of the splinters alone. Mr. Gruthrie, 4 who 
thinks excision may be practised in some instances where the 
splintering is confined to the head and neck of the humerus, 
adduces cases to prove that, even where the head of the bone 
is greatly shattered, it is not always necessary ; and Hennen, 5 
than whom we have no higher authority, states, that the prac- 
tice is not generally adopted, and "believes upon the whole 
that the excision of the head of the humerus will be found to 

1 Military Memoirs, trans, by Hall, vol. i. p. 330. 

2 Lecons Orales, torn. ii. p. 530. 3 Medical Sketches. 
4 On Gunshot Wounds, p. 5 Loc. cit., p. 40. 



172 CONTRIBUTIONS TO PRACTICAL SURGERY. 

be more imposing in the closet than generally applicable in 
the field." 

Since the period at which Hennen wrote there has been a 
marked change of opinion in the profession on the subject of 
excision of joints, and the operation has been extensively 
practised both in civil and military life in the shoulder, elbow, 
hip, and knee. In our late war 1 five hundred and seventy-five 
cases of excision of the shoulder-joint for gunshot fractures 
have been reported, in sixty-seven of which the results were 
undetermined. Setting these aside, we find of the two hun- 
dred and ten primary operations that fifty died, and one hun- 
dred and sixty recovered, a mortality of 23 per cent.; while two 
hundred and ninety-eight secondary operations gave one hun- 
dred and fifteen deaths and one hundred and eighty-three re- 
coveries, a ratio of 38.59 per cent., or a mean ratio of 32.48. 
" The ratio in amputation of the shoulder-joint," adds the com- 
piler, " is 39.24, a percentage of 6.76 in favor of excision." 

" Of thirty-six cases of gunshot fracture of the head of the 
humerus, selected as favorable cases for the expectant plan, 
and treated without excision or amputation, sixteen died, or 
44.4 per cent., a ratio in favor of excision of 11.96 per cent." 

Of two hundred and eighty-six cases at the elbow in which 
the results are ascertained, sixty-two cases terminated fatally, 
or 21.67 per cent., " which is a mortality a fraction greater 
than that resulting from amputations of the arm." 

In regard to the hip-joint, the statistics of the war give 
twenty-one cases of amputations of that part for gunshot frac- 
tures, of which nine were primary, and twelve secondary. Of 
these, two of the first class were successful, and one of the 
secondary. In the Crimean War the Operation was uniformly 
fatal. 2 

" Of the sixty-three cases submitted to excisions of the head, 
or of the head and neck and trochanters of the femur," thirty- 
two were primary, of which two succeeded ; twenty-two were 
intermediate, of which also two succeeded ; nine were second- 
ary, of which one alone did well. 3 

J Circular No. 6, Surgeon General's Office, p. 55, 1865. 

•2 Ibid., p. 49, 1865. 

s Circular No. 2, Surgeon General's Office, pp. 20-54, 1869. 



COMPOUND FRACTURES. 173 

"Among one hundred and twenty-two cases treated by 
temporization, cases in which the testimony is direct and 
positive that gunshot wounds of the hip-joint, with fractures 
of the head or neck of the femur had been detected by com- 
petent observers, eight examples of recovery are recorded. 
This gives a mortality of 93.04, a more deplorable result than 
either amputation or excision present." 1 

Dr. Otis, the able compiler of these statements, thinks, "a 
sufficient number of instances have been collected to permit 
precise rules on this subject to be established," and says : — 

" Amputation at the hip-joint for gunshot injury, notwith- 
standing its great fatality, cannot be altogether discarded 
and should be performed: 1. When the thigh is torn off, or 
the upper extremity of the bone comminuted with great lace- 
ration of the soft parts in such proximity to the trunk that 
amputation in the continuity is impracticable. 2. When a 
fracture of the head, neck, or trochanters of the femur is com- 
plicated with a wound of the femoral vessels. 3. When a 
gunshot fracture involving the hip-joint is complicated by a 
severe compound fracture of the limb lower down, or by a 
wound of the knee-joint." 

" Primary excisions of the head or upper extremity of the 
femur should be performed in all uncomplicated cases of gun- 
shot fracture of the head or neck." 

" Expectant treatment is to be condemned in all cases in 
which the diagnosis of direct injury to the articulation can be 
clearly established." 2 

When none of the circumstances are present demanding im- 
mediate amputation or resection, the fractured bone is to be 
reduced, and the wound dressed with a view to procuring its 
reunion. The attempt to promote union by the first intention 
should in favorable cases be made, though judging from what 
is said by writers, as well as from what I have seen in my own 
practice and that of others, this desirable result is rare in com- 
pound fractures. By attempting it, nevertheless, we lessen 
the inflammation which necessarily follows, diminish the dis- 

1 Ibid., p. 115, 18G9. * Ibid., pp. 122-3. 



174 CONTRIBUTIONS TO PRACTICAL SURGERY. 

charge of pus, and assist materially the union by granulation. 
Previous, however, to the dressing being arranged, the hem- 
orrhage, if any, is to be arrested, the clotted blood, loose 
splinters, and foreign bodies removed, and the wound care- 
fully cleaned. 

Hemorrhage. — The first thing which commands attention in 
the dressing is the arrest of hemorrhage. If this be arterial 
and free, pressure or a tourniquet should be applied over the 
main artery of the limb until the divided vessel can be secured, 
and in all cases where it can be done, both ends of the divided 
vessel, if large, should be tied. But mischief may be done by 
the long-continued application of a tourniquet, and it cannot 
be too forcibly impressed upon the young practitioner, that 
this instrument is never to be used except for mere temporary 
purposes. When kept long upon a limb, besides being pain- 
ful, cedematous swelling is sure to follow, and if its applica- 
tion be long continued, mortification would be the result. As 
a patient under such circumstances is always more or less 
chilled and prostrated, every vessel pouring out blood, even 
though of small size should be taken up, in order to avoid a 
recurrence of the bleeding when the parts become warm and 
reaction is established. Venous hemorrhage may always be 
arrested by rest and position, either alone, or combined with 
the application of cold, or moderate compression. 

Removal of foreign bodies. — Dirt or foreign bodies are to 
be carefully removed from the wound, including under this 
last head, all pieces of bone that are not adherent to the soft 
parts, and in an examination for these, or other purposes, the 
finger is at all times to be preferred to a probe. Some go so 
far as to recommend the removal of all loose fragments even 
though they be not entirely detached from the surrounding 
tissues, but the practice is reprehensible as well on account of 
the pain occasioned by it, as from the injurious effect which 
such removal exerts upon the length of the limb and the for- 
mation of callus. They should be left until they become 
spontaneously detached, and then removed. If the bone be 
greatly comminuted, or if splinters cannot be removed without 
causing pain and laceration of the soft parts, no objection ex- 



COMPOUND FRACTURES. 175 

ists to enlarging the wound, as by so doing we not only more 
easily get rid of the separated fragments, but also make a free 
exit for the discharge of pus. "Where the fracture is unat- 
tended with comminution, the propriety of such practice is 
doubtful, as in such cases we expose to the air a much larger 
surface of bone and thereby render it more liable to exfolia- 
tion. Care should be taken where loose but attached pieces 
exist, when reducing the fracture, to place them as nearly as 
possible in their natural situation. 

All foreign bodies and loose portions of bone being re- 
moved, the limb is to be placed in the position in which it is 
determined to keep it during the treatment, with the frag- 
ments, if possible, in accurate apposition, and such dressings 
applied as will be likely so to retain them. But supposing 
so long a time to have elapsed between the occurrence of the 
accident and the visit of the surgeon as to have allowed in- 
flammation to set in, is reduction to be at once attempted, or 
is it to be delayed till the great pain, heat, and swelling have 
in a degree subsided? The experience of practitioners of the 
present day teaches the propriety of at once reducing the 
bone, and thus getting rid of one great cause of the inflam- 
mation. This, however, is not to be done by the sudden 
application of force alone, but by moderate and gradual ex- 
tension, aided, if necessary, by enlargement of the wound, or 
removal of the end of the bone. Eecurrence of the displace- 
ment is afterwards to be prevented by giving a proper posi- 
tion and support to the limb without the aid of tight ban- 
dages or great pressure, measures which would risk increase 
of the inflammation, and which not unfrequently have induced 
mortification or sloughing. 

Position of the limb. — As in simple fractures of the lower 
extremity, two very opposite positions have been recommended 
for the treatment of compound cases. The bent position, ex- 
tolled by Pott on account of its relaxing the muscles, has 
since his time been generally preferred by his countrymen, 
while in France, the straight position has been mostly adopted. 
In this country, neither method is exclusively employed, and 
by neither are all the muscles completely relaxed. I have 



176 CONTRIBUTIONS TO PRACTICAL SURGERY. 

witnessed both modes of treatment, and know that by both 
good cures may be made, but give a preference to that of 
extending the limb, inasmuch as it is easier for the patient, 
as well as his attendants, and permits of less disturbance of 
the fragments, while its results are fully equal to any that 
can be attained by the position of Pott, or the semi-flexion 
of the knee with the patient on his back. It is a great mis- 
take to suppose the bent position to be the easier one for the 
patient. Hennen, who used the position recommended by 
Pott during the inflammatory stages of fractures, and after 
that period had passed placed the patient on his back, with 
his limb extended, when describing his treatment, says: "The 
patient is in general extremely tired of his relaxed position 
before the lowering of the inflammatory symptoms indicates 
the time for placing him on his back, a change from which 
he receives great relief," and in his reflections on the two 
positions gives the following strong testimony in favor of the 
straight one: "I am warrante'd, from ample experience, to 
infer that lying on the back, with the limb extended, is by 
far the most tolerable to the patient, and admits of much 
easier access and dressing; and, what is still more important, 
is, in its ultimate success, equal, if not superior, to either the 
bent position of Pott, the patient on his side; or the semi- 
flexion of the knee, the patient on his back." In compound 
fractures of the leg, I usually employ the common hinged 
box, and in those of the thigh, an apparatus on the plan re- 
commended by Boyer, previously sawing out a portion of the 
splint opposite to the seat of injury, so as to allow of the 
application of dressings without disturbance of the limb, or 
permanent extension made by means of a weight and pulley, 
with narrow sacks filled with sand applied to support the sides 
of the limb, affords excellent results. 

The important requisites for treating fractures successfully 
are coaptation and immobility, and in my judgment it matters 
little what particular apparatus is employed, provided it be 
made to fulfil these indications, and keep the limb quiet and 
firm, and admit of the dressings being removed and reapplied 



COMPOUND FRACTURES. 177 

without giving pain to the patient, or moving the fragments. 
The simpler the appliances the better. 

In compound fractures of the upper extremity, each case 
must require some particular adaptation of splints to it, 
though those ordinarily employed with openings opposite to 
the wounded part, or one carved to fit the limb, are mostly 
all that are required, taking care to keep the patient in bed, 
with the limb supported on a pillow till all fever subsides, 
and afterwards allowing him to move about with the part 
sustained by a sling. In compound fractures about the joints, 
where attempts are made to save the limb, the bones should 
be adjusted in that position in which the limb, if anchylosed, 
will be most useful to the patient. If the fracture extend 
near to the knee-joint, the straight position is to be chosen ; 
if the elbow be concerned a right angle, and if the fragments 
cannot be so placed immediately after their occurrence, they 
should gradually be brought into it as soon as the inflamma- 
tion subsides. Where joints in these cases are for a long 
time retained in a perfectly motionlesss state, strong adhesions 
of the surrounding tissues take place, unless some degree of 
passive motion be daily given to them, and this should be 
done by gently flexing and extending the articulation, but it 
is not to be begun till all inflammation has subsided, and some 
degree of union has taken place. If, however, any irritation 
is caused by this procedure, it should be allowed entirely to 
subside before the part is again moved, as otherwise we risk 
the occurrence of inflammation at the seat of injury, which, 
if severe, might terminate in profuse suppuration, and result 
in the loss of the limb. 

Usually, the extremity is readily placed in a good position, 
but if difficulty should arise in reducing the protruding bone, 
it can mostly be overcome by placing it so as to relax its 
muscles, after which extension is to be made on the inferior 
fragment and the parts restored to their natural situation. But 
where the fracture has been caused by the application of force 
to the extremities of a boile, and where consequently the 
wound has been produced by the fragment, the smallness of 
the opening, by embracing it very tightly, may prevent the 



178 CONTRIBUTIONS TO PRACTICAL SURGERY. 

reduction — here the wound may be slightly enlarged, after 
which the reduction is to be again attempted, and will mostly 
be easily accomplished. If difficulty, however, is experienced 
after enlargement of the wound, and well-directed efforts to 
reduce the fracture, it is better to remove a small portion of 
the bone, than make use of much violence either to return it, 
or retain it in position, though as but few cases happen in 
which a fractured bone may not be replaced by giving the 
limb a proper position, and assisting it, if necessary, by 
enlargement of the wound, such a procedure is seldom abso- 
lutely required. During a period of three years that I held 
the place of resident surgeon in the Pennsylvania Hospital, 
where a large number of these accidents are received, there 
occurred but one case in which it became necessary to resort 
to resection of the bone, and in the course of twenty-seven 
years that I acted as one of the surgeons of the institution, 
I have witnessed but very few cases which required it in 
order to replace the fragment. But though this procedure be 
seldom absolutely demanded, it is a question whether in cases 
where, from obliquity or other causes, the bones, despite all 
proper attention, are likely to protrude after reduction, or 
require the application of much force to retain them in a 
proper position, it is not better to remove a portion of it, as 
by so doing we get rid of all tension about the seat of injury, 
at the same time that a free exit is made for the discharge of 
matter. Resection of the extremity of a bone in compound 
fractures, which with difficulty could be maintained in posi- 
tion after reduction, or which were altogether irreducible, 
was a common practice with the ancients, and by our imme- 
diate predecessors was looked upon as being often demanded, 
and it may be questioned whether the practice at this day is 
not too much neglected. Albucasis, 1 Fabricius, and most of 
the ancient writers direct resection of the ends in these cases, 
sufficiently to allow of their easy reduction. Duverney 2 was 
a strong advocate for this practice, he says: " If in a fracture 
with wound, one or both ends of the bone start out, and after 

1 Diet, de Med., torn. xii. p. 504. 2 Trans, by Ingham, p. 41. 



COMPOUND FRACTURES. 179 

trial to leplace them, it cannot be effected through the danger 
of dilating the wound too much, as when it is very near the 
joint of the foot or knee, it should be sawed or cut with inci- 
sive pincers, especially if a considerable portion of each end 
was stripped of its periosteum." Towards the close of the 
last, and beginning of the present, century, after the work of 
Pott had drawn particular attention to these accidents, many 
cases were published proving the efficacy of this procedure, 
and judging from th# reports of these writers, it appears to 
have been at that time a favorite and happy practice. Grooch, 
in thirteen compound fractures, sawed off a considerable por- 
tion of the tibia and succeeded in curing both young and old 
subjects. 1 Sir George Ballingall, a writer of our own day, 
thinks, "that he has too frequently seen a reluctance to use 
the saw in removing the protruding extremities of the bone, 
when these were either difficult to reduce or of a sharp or 
spicular form." 2 The experience of Mr. Hilton, Surgeon to 
the Liverpool Infirmary, who has employed this practice ex- 
tensively, is very favorable to it. In a period of twenty-two 
years, he sawed off portions of the fractured fragments in 
thirty- five cases of severe compound fractures of the leg, in 
which amputation of the limb was not considered justifiable, 
and lost only four cases — in the thigh of three cases of a 
similar nature, one died ; of four instances in the humerus, 
one died; and of seven in the forearm and hand, two died. 3 
Protrusion of the bones alone, however great in degree, can 
never be a sufficient cause for amputation. It has been stated 
as an objection to the practice of resecting the extremities of 
a fractured bone, that we risk in employing it the production 
of a false joint at the part, and the experiments of Sir Astley 
Cooper and others upon the inferior animals have been cited 
to show that by excising portions of bone no reproduction of 
the tissue occurred where the extremities were kept asunder. 
Cases too have been reported by Cooper 4 and Theden, 5 which 

1 Works, vol. ii. p. 286. 2 Outlines, p. 336, 1838. 

3 London Med. Gazette, Dec. 1843, p. 396. 

* On Fractures and Luxations, 4to. p. 116. 

5 Med. Operat. of Velpeau, torn. ii. p. 565, 1839. 



180 CONTRIBUTIONS TO PRACTICAL SURGERY. 

show the same thing to have followed the removal of portions 
of the osseous tissue in man. These experiments and cases, it 
should be remembered, occurred in limbs composed of two 
bones, and the loss of a part of one of them without simul- 
taneous fracture of the other, by preventing their being 
placed in contact, might well hinder firm consolidation. Yery 
different, however, would be the result in parts in which a 
single bone exists, and we should be cautious in making a 
too absolute application of experiments, on the formation of 
callus to cases of fracture with loss of substance, as facts of 
an opposite kind in great numbers might readily be adduced. 
The records of our science show that false joint rarely follows 
the resection of the ends of a broken bone in recent fractures, 
where the after-treatment is judicious and no general cause is 
present in the system to prevent consolidation. 

Closure of the wound. — The fracture being reduced, the next 
step in the treatment is to close the wound, and promote its 
union by the first intention. For this purpose sutures were 
formerly much employed, but, on account of the pain pro- 
duced in their application, their liability to excite inflamma- 
tion, and the unequal pressure made by them upon the wound, 
they are now rarely used. Strips of adhesive plaster of such 
a length as to retain the parts in close contact when they can 
be so placed, without the use of forcible or long-continued 
means to produce it, and at such distances as to allow of the 
escape of matter when formed, are with us generally used for 
this purpose, the many-tailed bandage being afterwards ap- 
plied. The use of these means will not, however, in the 
great majority of instances, be found to produce immediate 
union of the wound, and it is probable that the old practice 
of imbuing a piece of lint in blood, and allowing it to dry 
over the injured part, was more generally successful. It is, 
however, only in those compound fractures produced by the 
application of indirect force alone, that the attempt to effect 
union by the first intention is to be recommended. In these 
the skin and soft parts are in general but little injured, and 
the wound is mostly but of small extent, and where such is 
the nature of the accident, the practice of bringing accurately 



COMPOUND FRACTURES. 181 

together the sides of the wound, even though the skin be 
extensively divided, should always be tried, and will not un- 
frequently be followed with good success. Where the injury 
has been produced by direct force, so much laceration and 
contusion usually accompany it, that no probability exists 
of procuring union, and even should the external opening 
under such circumstances be closed, the inflammation of the 
deeper seated tissues will terminate in suppuration, and necessi- 
tate a reopening of it ; the pressure too made upon the limb 
by the adhesive strips, bandage, lint imbued in blood, or other 
means used in our attempts to produce it, only tends to aggra- 
vate this inflammation and increase the danger and extent of 
the suppurating surface. In such cases, therefore, the practice 
is to be deprecated. As little pressure as is compatible with 
keeping the bones reduced should be applied, and dressings 
of the lightest kinds only in temperate or warm weather, and 
a soft poultice, or lint with tepid water in the winter season, 
are more appropriate applications. 

Many writers of the present day profess aversion to poul- 
tices, and decry them as greasy and irritating applications. 
My own experience leads me to look upon them when pro- 
perly made, and covered with oiled silk, and not suffered to 
remain on the part till they become dry, stiff and sour, or 
not so heavy as to irritate by their weight, as applications of 
the most agreeable and comforting kind during the existence 
of high inflammation, or the sloughing process. In all cases 
their use should be discontinued upon the subsidence of the 
swelling and inflammation, as they then but encourage sup- 
puration, and retard the healing of the wound. 

Where the discharge of pus becomes profuse, or where 
hemorrhage from the veins or small arteries, either primary 
or secondary is troublesome, or is to be looked for, an ex- 
cellent mode of treatment consists in fixing the limb in a 
good position in a fracture-box on a bed of dry bran, and sur- 
rounding and enveloping it with the same material. This ap- 
plication is soft, and agreeable to the patient, makes moderate 
and very equable pressure, which is increased in proportion to 
the increase of the hemorrhage or purulent discharge by the 



182 CONTRIBUTIONS TO PRACTICAL SURGERY. 

bran becoming moistened and expanding, and is unirritating to 
the wound, at the same time that it may be removed with the 
aid of a spatula or syringe, and reapplied without causing pain 
or disturbing in any degree the limb. No mode of dressing 
that I have ever made use of can be compared to that with 
bran in injuries of this kind attended with profuse suppuration, 
during our extreme hot weather. At this season the fetor 
arising from the discharge is often so powerful as to taint the 
air of a chamber, and in such cases maggots are generated in 
the course of a few hours, if the wound be in the slightest 
degree exposed. Clean bran, by covering completely and 
closely every part of the injured surface, hinders the deposit 
of the ova of flies, and at the same time prevents, in a great 
degree, the odor that would otherwise arise, by rapidly and 
effectually absorbing the discharge. It affords too an excel- 
lent means of applying cold by means of an iced bag laid on 
the surface, if on account of commencing inflammation it be 
judged necessary. The addition of carbolic acid to the dress- 
ing is also of service as a disinfectant, and tends to drive 
away the flies. 

Water dressing. — The water dressing has of late years at- 
tracted much attention. In consists in one or two layers of 
lint folded and soaked in water, which are laid over the part 
and wetted as often as occasion may require. In cold weather, 
the lint should be re-soaked several times a da}', and closely 
covered with oiled silk, to prevent evaporation. The con- 
tinued application of cold water by means of the syphon has 
also been used in these injuries, and in hot weather will be 
found an agreeable and very effectual means of preventing or 
reducing a too high degree of inflammation, and its conse- 
quence excessive suppuration. 

The following is a good mode of application : The fracture 
being reduced and well secured in a fracture-box, or other 
apparatus, the pillow upon which the extremity is placed 
being first properly protected by oiled silk or caoutchouc, 
and the wound covered with lint, and if necessary, the sides 
of it drawn together with adhesive plaster ; one end of a long 
strip of lint is placed in a basin of cold water fixed on a table 



COMPOUND FRACTURES. 183 

near to and above the level of the part, while the other end 
is laid over the lint covering the wound. This acting by 
capillary attraction keeps up a continuous irrigation of the 
parts, the water being carried off by causing another strip to 
connect the dressings with an empty basin placed upon the 
floor. The water may be made of a low temperature by the 
addition of ice, or medicated lotions may, if wished, be sub- 
stituted for it. The treatment by irrigation is best adapted 
to the early stages of such fractures as occur in hot weather, 
and are accompanied by great laceration and contusion, hinder- 
ing, as it often then does, excessive inflammation and being 
agreeable to the feelings of the patient. Except at this season, 
I am disinclined to its use, believing its employment to favor 
attacks of inflammation of the respiratory organs. 

Immovable apparatus. — By any of the above methods of 
treatment, the dressings applied require frequent renewal, 
and the bad effects of daily disturbing them have been much 
dwelt on by some who look upon it as one cause of a high 
degree of inflammation following these accidents, and to pre- 
vent which they employ an apparatus which, by embracing 
the whole limb, renders the fragments perfectly immovable, 
and prevents the necessity of a renewal of them. Larrey, the 
introducer of the immovable apparatus to the notice of the 
surgeons of the present day, recommends, after the removal 
of foreign bodies, tying up the arteries, and cleaning out all 
extraneous matters and clotted blood, to bring the edges of 
the wound into apposition by means of perforated compresses 
spread with simple ointment, over which lint is to be laid, 
and then additional compresses imbued in some styptic gelati- 
nous liquor. These dressings should be made to fit every 
part of the limb with great exactness, and upon becoming 
hard supply the place of splints. When the compresses are 
all applied, the many-tailed bandage is placed over them, and 
the dressings allowed to remain on during the whole period 
of cure. The use of the immovable apparatus in open frac- 
tures is directly opposed to that recommended by Pott, and 
generally adopted with us, viz., of dressing accidents of this 
class every twenty-four hours, and the advantages it pos- 



184 CONTRIBUTIONS TO PRACTICAL SURGERY. 

sesses over this latter treatment are asserted by its advocates 
to be : — 

1st. That it prevents effectually all contact of the air. 

2d. That it diminishes the abundance of the suppuration. 

3d. That it maintains the parts in a state of exact apposition. 

That this treatment in compound fractures has been in very 
numerous cases followed with good effects by its introducer 
and his pupils, as well as by its more recent advocates, cannot 
be doubted, but the frequent occurrence of severe inflamma- 
tion, abscesses, gangrene, and want of union, and where cures 
occur, the deformities seen in the hospital services in which it 
has been used, leads me here, as in simple fractures, to con- 
demn its general employment. Its chief value is, I think, to 
be found in its adaptation to military surgery. In civil prac- 
tice, it is particularly objectionable when placed upon the 
limb immediately after the occurrence of the accident. 

The immovable apparatus has found great favor among the 
German surgeons. They usually employ the plaster of Paris 
as their immobilizing agent, and cut windows in it opposite 
the wound to give exit to the discharge. 

Frequency of dressing. — The limb being placed and properly 
fixed in a good position by any mode of dressing which may 
be adopted, close watching on the part of the surgeon is 
necessary to insure a continuance of it. Until all inflam- 
matory fever has subsided, which usually continues from ten 
to fifteen days, great irritability of the muscles with spas- 
modic contraction is sometimes observed, the dressings should 
be examined twice in the twenty-four hours, to guard against 
unequal pressure in any part, and correct any bad position 
that may have been assumed. Except where the immovable 
apparatus is emploj^ed, the wound at the morning visit should 
be regularly dressed, all discharges being removed, collections 
of pus opened, soiled dressings changed, and cleanliness par- 
ticularly attended to. After the inflammation has abated, and 
the discharge is lessened, one dressing in the same period of 
time will suffice. To prevent the bed from becoming moist- 
ened ancl soiled, oiled silk or rubber cloth should be placed 
beneath the limb, and this together with the pillows and 



COMPOUND FRACTURES. 185 

sheets upon which the patient is placed, and his body linen, 
occasionally changed. These various offices should all be 
done in the gentlest manner under the immediate superintend- 
ence of the surgeon himself and without effort on the part of 
the patient. In both hospital and private practice, duties such 
as these are sometimes left to the nurse, and generally to the 
detriment of the patient. In well-regulated hospitals or with 
careful practitioners no bandages, no tightening or relaxing 
of an apparatus, dressing of the wound, important change of 
position, or handling of the limb of any kind is ever per- 
mitted except under the immediate superintendence of the 
surgeon or an experienced attendant. In fractures of the 
lower extremity, cradles made of hoop or wire should invari- 
ably be placed over the foot, to prevent the bedclothes from 
resting upon it, as deformity not unfrequently follows a neglect 
of this precaution. 

In the leg, when the patient becomes restless during the 
treatment, good results may sometimes be attained by sus- 
pending the limb in a swing, using for that purpose either a 
fracture-box, an anterior splint, or such other form of appa- 
ratus as the practitioner may deem most suitable. 

Complicated fractures. — The most common complications of 
compound fractures are, rupture of a large vein, nerve, or 
artery, previous disease of the bone, or luxation. 

The hemorrhage resulting from the rupture of a vein, even 
when it be large, is in most cases readily checked by cold ap- 
plications to the part assisted by a slight elevation of the foot 
of the bedstead, or moderate pressure with a pledget of lint ; 
but there is always danger of mischief supervening upon it. 

Laceration of a large nerve. — The diagnosis of this is easy, 
the paralysis that takes place below the seat of injury at once 
making it known, and, when occurring as it mostly does with 
wound of the artery, amputation is our only resource. Par- 
tial rupture of nervous trunks is followed by convulsive 
twitchings, severe pain, and partial palsy. In these cases, 
warm fomentations or poultices, together with the free use of 
opium, is the only treatment likely to afford any relief. 

Rupture of an artery in compound fractures is at once made 
13 



186 CONTRIBUTIONS TO PRACTICAL SU-ROERT. 

known by the degree of hemorrhage which occurs, the color 
of the blood thrown out, as well as by the flow being ejected 
per saltum. Should the artery divided be superficial, or the 
wound large and of recent occurrence, the application of a 
ligature to both ends of the vessel is required, but where the 
bleeding vessel is deeply seated, or the wound small, or 
several hours have elapsed since the occurrence of the injury, 
and great swelling be present, it is better to proceed at once to 
secure the main vessel of the extremity. 

In these cases, which formerly were supposed always to 
require immediate amputation, the main artery of the limb 
has in several instances been secured and the treatment after- 
wards conducted to a safe termination. In a compound frac- 
ture of the leg complicated with wound of the posterior tibial 
artery, Dupuytren tied the femoral in order to arrest the 
bleeding, and the fracture, which was afterwards treated by the 
ordinary means, united well in a little more than the usual 
time. 1 In another case of fracture accompanied by wound of 
the popliteal artery, he afterwards pursued a like practice 
with similar success. In an instance of hemorrhage from the 
posterior tibial artery accompanying sloughing after a com- 
pound fracture of the leg, Mr. Syme secured the femoral, and 
firm bony union occurred in two months after the operation, 
although the woman was advanced in life (aetat. 82). 2 Like 
results have been published by Pelletan, Delpech, B. Cooper, 
Gerdy, and others. 

Wound of the main artery, however, is in itself highly 
dangerous, and it is only in cases otherwise favorable that an 
attempt to save a compound fracture complicated with it is 
justifiable. 

Disease of the bone. — These fractures may be complicated 
by previous disease of the bone. Some years ago I treated a 
case of this kind occurring in a carious tibia, and necessitating 
amputation — a practice which will mostly be requisite in this 
class of cases. 

1 Lemons Orales, torn. iv. p. 618. 

2 London and Edinburgh Monthly Journal, 1842, p. 965. 



COMPOUND FRACTURES. 187 

Luxation. — As in the simple and more common forms of 
fracture, those which are open ma} 7 " be accompanied by dislo- 
cation. When this occurs, the misplaced bone should be at 
once returned to its socket, before permanently arranging the 
fracture. In the ginglymoidal joints this is generally accom- 
plished, but in the orbicular ones, where the dislocated frag- 
ment is short, and the articulation surrounded by powerful 
muscles, it is more difficult, and sometimes even impossible. 
Everv effort, however, should be made to reduce the disloca- 
tion, and if the fragment be sufficiently long to allow of its 
seizure, trials to return the head of the bone should not be 
relaxed till crowned with success. In case of a compound 
fracture occurring in an extremity, with a luxation of some 
other limb, the same conduct is always to be pursued, viz., at 
once to reduce the displaced bone. 

During the regular treatment of compound fractures, acci- 
dents may occur which it will be proper to notice. 

Delirium tremens is not unfrequently met with in hospital 
practice, in connection with fractured limbs, and is uniformly 
attended with much danger. It usually shows itself in thirty- 
six or forty-eight hours after the accident, and from the period 
of its setting in little or nothing can be done in the way of 
treatment for the fracture. The best method of managing 
compound fractures of the leg or arm, during an attack, is to 
bring the sides of the wound together with adhesive plaster, 
and after securing compresses of soft lint or charpie over the 
wound by the same means, to envelop the limb in a pillow. 
This should be large and well stuffed, and should be bound 
securely around the limb by means of a roller. The elasticity 
of the feathers is such that no fear of making too much pres- 
sure on the part need be entertained, and it will be found to 
hinder all motion, and to keep the fragments in apposition better 
than any more complicated apparatus : the limb bound up in 
the pillow is, of course, either to be secured to the bedstead, or 
what is better, held by an attendant. The treatment commonly 
pursued in our hospital in cases of delirium tremens is the use 
of opium in the early stages, gr. ij or iij, every two hours, 
beginning its use in the latter part of the day, and discontinu- 



188 CONTRIBUTIONS TO PRACTICAL SURGERY. 

ing it towards midnight, together with nourishing soups, and 
the moderate use of stimuli. The latter are generally given 
in the form of porter, brandy, and tonic and anti -spasmodic 
tinctures. In the latter stages of the disease, when the pupil 
becomes contracted, the opium is either omitted or very con- 
siderably diminished, and blisters are applied over the back 
of the head and neck. 

Retention of urine is a frequent occurrence in bad fractures, 
arising in most instances from an inability to empty the 
bladder in the horizontal position. It generally occurs soon 
after the accident, and the surgeon in all cases should take 
care to ascertain that the functions of this viscus are properly 
performed. When retention exists, the catheter is the proper 
remedy, and it mostly happens that after a few introductions 
of it the habit of passing the urine is acquired in any position 
in which the patient may have been placed. 

Erysipelas is observed sometimes to attack the class of in- 
juries of which we are treating. It is generally heralded by 
a sense of coldness, or a distinct chill with nausea or bilious 
vomiting, and these are quickly followed by fever oftentimes 
of a severe kind. The tongue is heavily coated, and the appe- 
tite fails. The parts around the fracture become reddened, 
and more or less swelled and painful, and the discharge from 
the wound is for a time lessened and more ichorous in its 
nature. The treatment is simple — a mild mercurial purge in 
the commencement, followed by the use of effervescing or 
neutral mixtures, and the moderate use of tinct. ferri chloridi 
in doses of fifteen or twenty drops, when the fever runs high, 
and cooling drinks, are all the constitutional means required, 
and these combined, with the application of mild poultices to 
the wound and cold mucilage or washes to the inflamed sur- 
face, will in most instances suffice for a cure. A large hos- 
pital experience does not warrant me in recommending iodine, 
nitrate of silver, and other like preparations for the purpose 
of preventing the spread of erysipelas. 

Collections of matter in the neighborhood of the wound often 
occur, as a consequence of erysipelas or other inflammation in 
the fractured limb, for the evacuation of which counter open- 



COMPOUND FRACTURES. 189 

ings sufficient to allow of the free exit should be early made, 
and if possible in a depending situation. All surgeons agree 
in the good effects of these counter openings; the wound im- 
proves in appearance after them, the constitutional irritation 
and sufferings of the patient abate, and the appetite and 
strength rapidly augment. 

Maggots. — The presence of maggots in the wound is often 
observed in our climate in open fractures during the heats of 
summer, and besides being unpleasant objects to the patient 
and his attendants, give rise when numerous to a disagreeable 
sensation of tickling in the part. The most effectual way of 
preventing their formation is by attention to cleanliness and 
hindering the deposit of the eggs of the fly by giving to the 
injured limb a complete covering with some light dressing. 
When once generated they are to be got rid of by directing a 
stream of cold water, or weak vinegar and water, over the 
part by means of a sponge or syringe, or by incorporating 
with the dressing some substance which is disagreeable to 
them, as carbolic acid, the tar or creasote ointments, etc. It 
has been observed that maggots avoid the living parts, while 
they seem greedy of the putrid matters discharged from a 
sore, and hasten the separation of sloughs, and it is thought 
by some that their presence in wounds is rather favorable 
than otherwise. I have rarely seen them where the discharge 
from a wound was thin, ichorous, and stinking, or the ulcer 
presenting a bad aspect. They are almost invariably found 
where the discharge is thick and creamy, and the granulations 
healthy and advancing towards cicatrization. 

Excoriations and bedsores. — Extension and counter-extension 
being required in compound as in simple fractures, excoria- 
tions are apt to occur at the points pressed upon. To avoid 
all risk of this, the extension should never be violent enough 
to cause pain, but should be moderate, steady, and permanent. 
If constant pain is complained of at any point on which the 
dressings press, it should be immediately examined and re- 
adjusted. The restlessness of patients causes any apparatus 
to be easily displaced, and it is therefore necessary to smooth, 
tighten, and carefully re-examine it daily. Excoriation of the 



190 CONTRIBUTIONS TO PRACTICAL SURGERY. 

heel is most frequently produced by want of care in not having 
the extending band smoothly applied to the part, or by tighten- 
ing it in too great a degree without having previously drawn 
down the limb with the hand. Sometimes, however, ulcera- 
tion at this part is caused by the weight of the foot alone, and 
in these cases the application of a piece of kid spread with soap 
cerate, together with slight elevation of the heel by means of 
a small cushion of old linen or carded cotton, will mostly 
prevent it. 

In patients who are long confined to one position in bed 
from any cause, continued pressure by obstructing the circula- 
tion in parts which have become debilitated, gives rise to 
ulcerations over the projecting parts of the skeleton, and their 
occasional occurrence in bad cases of compound fractures, 
from the length of time the patient is obliged to remain in 
one position, requires some notice of them in this place. Per- 
sons of lax fibre, and those inclined to corpulence, seem 
peculiarly predisposed to bed-sores, though they are most 
frequently seen in elderly persons. Occasionally they are ob- 
served to form rapidly in the young and robust, particularly 
when a disposition is shown by the wound to take on an in- 
flammatory or sloughy action. In these states the surgeon 
should ever be on his guard in relation to them, inasmuch as 
they are often found to progress considerably without any 
complaint being made by the patient. The heel, the sacrum, 
ossa ilia, trochanters, scapulae, and spinous processes of the 
vertebras, are the parts most frequently affected. The skin, 
when about to take on the ulcerative action in these cases, 
presents a dull red color aud becomes soft and oedematous, 
and if, when these symptoms show themselves, pressure be 
not at once removed from the part and means used to stimu- 
late the debilitated vessels, the point at which the pressure is 
greatest assumes a leaden or blackish hue. The slough 
rapidly extends to all the parts pressed upon, and on its sepa- 
ration gives rise to an ulcer of bad character in which not un- 
frequently the bones are exposed. Aware of their frequency, 
the surgeon should from the beginning endeavor to guard 
against their occurrence, and in this respect much may be done 



COMPOUND FRACTURES. 191 

by having the patient placed on a proper bed, preventing the 
sheets or his body linen from becoming creased or moist, and 
if allowable, occasionally with the assistance of intelligent 
assistants, changing him from bed to bed. A hair mattress, 
well stuffed, and rather hard than otherwise, should be 
selected, and the support for it be made either of iron or 
wood so as to be perfectly firm; in private practice if a sack- 
ing bottom bedstead is to be employed, it should be made firm 
by placing boards beneath the mattress. The sheet should be 
drawn tightly over the mattress, and this, together with the 
clothing of the patient, is to be carefully smoothed when 
displaced. If it be impossible to move the patient from bed 
to bed, the parts pressed upon should be frequently examined, 
and on the appearance of any discoloration, or complaint of 
uneasiness, should be daily bathed with a little spirits or soap 
liniment, and when any spot is unduly pressed upon, the weight 
of the body should be entirely removed from it by means of 
an air or water-bed, air-cushions, circular hollow pillows, or 
supports of carded cotton, or if these be impossible, by apply- 
ing over it a large piece of kid spread with soap cerate. An 
air-bed is sometimes extremely useful. When, either from 
pressure made on the parts, or the action of the extending or 
counter-extending bands, sloughing has actually taken place, 
a flaxseed or carrot poultice, frequently renewed till the 
slough be separated, and afterwards an unirritating plaster, 
are perhaps the best applications, increased attention being 
at the same time given to relieve the part from the support of 
the weight of the body. Proper constitutional treatment is 
likewise to be carefully observed : the allowance of a generous 
diet with the use of porter and stimulants, the administration 
of tonics such as quinine, etc., attention to cleanliness, ventila- 
tion, and all other hygienic measures, will be found to exert a 
marked beneficial influence on these local affections. 

Tetanus sometimes follows upon compound fractures, though 
from my own observation but rarely. A few years ago, I lost 
a case from this cause in the Pennsylvania Hospital. The 
subject of it was a young and healthy countryman who was 
admitted five or six days after a comminuted fracture of the 



192 CONTRIBUTIONS TO PRACTICAL SURGERY. 

forearm produced by an injury from a rail-car. According 
to the statement made by him, his fracture had been compli- 
cated with wound of a large artery, the hemorrhage from which 
had been arrested by pressure. The arm was bound up in 
splints, and when he presented himself the hand and forearm 
were completely mortified, and separation of the dead from the 
living parts had considerably advanced. To get rid of its 
great fetor I clipped off the mortified parts with scissors at 
the point of fracture without causing pain, and covered the 
part with a cataplasm, intending, after improvement of his 
general symptoms, to amputate. On the evening of the second 
day after admission, slight stiffness of the jaws was observed, 
and on the following morning well-marked tetanus was pre- 
sent, which terminated fatally on the third day. His treat- 
ment consisted in purging, the free use of opium combined 
with a small portion of calomel and stimulants, together with 
the application of cups and blisters to the spine, and poultices 
to the wound, a treatment which both my reading and ob- 
servation lead me to think the best that we possess. Larrey 
has recommended amputation in cases of tetanus, but the prac- 
tice has never been generally followed. Mr. Hammick, a 
surgeon who enjoyed good opportunities of witnessing the 
effect of amputation in these cases, thus speaks of it: "I have 
done it ; I have seen it done ; but all the patients died with 
an aggravation of their symptoms to a frightful extent." 1 Du- 
puytren also condemns it. Division of the principal nerves 
leading to the seat of injury has also been advised and prac- 
tised, though with no better effect than amputation. The use 
of opium to allay suffering and soothe the mind after severe 
injuries, together with a diet not too low, and care to prevent 
exposure to drafts of air, assist very materially in preventing 
its occurrence, and attention to these apparently minute points 
cannot be too much or too often insisted upon. 

The Calabar bean and chloroform have latterly been much 
commended, but I have not experimented with them. Ether 
I have known to be very freely used without benefit. 

1 On Amputations and Fractures, p. 75. 



COMPOUND FRACTURES. 193 

Secondary inflammation and deposits of pus in distant parts. — 
One of the most dangerous complications that can happen as 
a consequence of severe injuries or operations, is the occur- 
rence of secondary inflammations and abscesses in the internal 
organs, and as these are perhaps seen more frequently after 
compound fractures than any other class of injuries, it seems 
peculiarly proper to notice them in this place. Deposits of 
pus in the internal organs after severe injuries have been long 
observed. Pare', Valsalva, and Morgagni all make mention 
of them, and the latter has described them with some detail. 
Qaesnay, Andouille, and Bertrandi noticed the occurrence of 
abscesses in the liver after injuries of the cranium, and con- 
tributed to the French Academy of Surgery interesting papers 
on the subject. J. L. Petit 1 describes them with exactitude, 
and many of the more modern surgeons have mentioned their 
occurrence. It remained, however, principally for the patho- 
logists of the present day to direct the attention of surgeons 
to their importance and frequency, as well as to elucidate their 
causes and mode of formation. 

Secondary deposits may occur at any time during the treat- 
ment of persons who have undergone any surgical operation, 
or have suffered from injuries attended with suppuration, 
though usually it is about the tenth day from the date of these 
that they are first observed. No age nor class of patients is 
exempt from them, though they may be said to be more com- 
mon in hospital practice, and among free livers, than in those 
of an opposite class ; they are also more frequently observed 
after amputations performed for injuries than those done for 
chronic diseases. They are often formed with great rapidity, 
and in some instances their first symptoms are so obscure and 
insidious as scarcely to be noticed ; the following signs, when 
occurring in the classes of cases we have mentioned, may lead 
to a suspicion of their formation. Marked rigors which re- 
turn at irregular intervals, or a sense of chilliness of some 
hours' duration, and in some cases coldness of the limbs alone, 
mostly usher in the affection. Upon the subsidence of these, 

1 Maladies Chirurgicales, torn. i. p. 6. 



194 CONTRIBUTIONS TO PRACTICAL SURGERY. 

the skin for a short time is hot, and occasionally is covered 
with moisture, and soon takes a cadaverous aspect, becoming 
pallid and assuming a yellowish or livid hue. After a re- 
newal of one or more of these paroxysms, returning at varia- 
ble intervals, the symptoms above mentioned are followed by 
those of a low and typhoid state. The eyes are sunken and 
glassy, the sclerotica and parts around the mouth assume a 
yellowish tint, the features become sharp, and the counten- 
ance presents a peculiar anxious appearance. The tongue, at 
first moist, soon becomes dry and red at its edges. The pulse 
is rapid, rarely below a hundred, and without force. The 
abdomen becomes distended, and not unfrequently there is a 
disposition to diarrhoea. Absolute delirium rarely occurs, 
though generally either marked depression of spirits or slight 
wandering is observable. 

In addition to the foregoing symptoms, inflammation of 
some of the internal organs may arise. When the lungs are 
the seat of the deposit, slight cough or pain in the chest, with 
dyspnoea and great anxiety, is observed, though in the ma- 
jority of cases unattended with effusion into the pleura, neither 
percussion nor auscultation assists materially in the diagnosis, 
the deposits being so small and so much scattered as to leave 
between their seats sufficient healthy tissue to prevent the 
detection of any deviation from the natural respiratory mur- 
murs. When the liver is the seat of the affection, jaundice 
more or less marked, attended with pain or uneasiness in the 
region of the liver or right shoulder, and vomiting, some- 
times are observed, though in many cases where this viscus 
is affected all these characteristic signs are wanting. The 
thirst generally is not excessive. The breath, often fetid, ex- 
hales a true purulent odor. Coincident with the occurrence 
of the symptoms just described, the work of cicatrization is 
suspended in the wound, which takes on an unhealthy sloughy 
aspect, the discharge from it becoming scanty, ichorous, and 
exceedingly offensive. Slight hemorrhages occur from its 
surface, the edges become detached and loose, as if the cellular 
tissue uniting the parts had been destroyed, and present like 
the rest of the surface a pallid appearance, while at the same 



COMPOUND FRACTURES. 195 

time the affected extremity becomes more or less oedematous. 
At a more advanced stage, a thin bloody discbarge escapes, 
which towards the termination of the disease resembles the 
washings of flesh. Sometimes there is absolute hemorrhage, 
which by frequent repetition carries off the patient. 

Examinations of patients who have died with the above 
symptoms present lesions of various kinds, though all refera- 
ble to the same cause. Most frequently numerous deposits of 
pus are found in the proper tissue of the viscera, or collections 
of puruloid serum in the serous cavities. These deposits have 
been found in all parts of the body, the brain, the heart, the 
kidneys, spleen, and even in the mediastina, the thyroid gland, 
and the loose cellular tissue of the extremities. The lungs 
and liver are their most common seat, and their characters in 
these organs are so marked, that it is scarcely possible to con- 
found them with the results of ordinary inflammations. Gen- 
erally they are seated near the surfaces of these viscera, are 
numerous, and varying in size from a hemp seed to that of a 
small nut. When pressed upon they feel like tubercles, and 
the surface of the viscus containing them is uneven to the 
touch. In the liver they are larger and are more central than 
in the other organs, and the matter forming them is more 
unequal in consistence, being very fluid in the interior and 
concrete on approaching their circumference. In the lungs 
the different phases of the deposit can be best seen. The pos- 
terior parts of these organs are more commonly affected than 
the anterior, and the lower lobes more frequently than the 
upper. In some parts of the lung they present the appearance 
of small circumscribed spots resembling petechias, while in 
others, the centres of these spots are marked by yellow points 
as if the seat of small drops of pus, and at other places the 
ecchymosed spots are nowhere visible, the purulent drops 
alone being perceptible. These are either concrete like cheesy 
tubercle or altogether fluid, some of them being encysted and 
others not. The tissue of the lung immediately around the 
abscesses sometimes presents a perfectly normal appearance, 
and after the matter has been removed and the parts washed, 
portions of it seem to have been dug out mechanically, while 



196 CONTRIBUTIONS TO PRACTICAL SURGERY. 

in others, the pulmonary tissue is more vascular, heavy, 
harder, and more friable than in a state of health. 

Of the serous cavities the pleura is their most common seat. 
In a few days the matter thrown out is very considerable, and 
the membrane, scarcely changed in character, is covered with 
a layer of true pus of greater or less consistence, while the 
remainder of the liquid has an ashy tint. 

In the articulations the state of the tissues is equally sur- 
prising : the cartilages, capsular ligaments, and other textures 
entering into their composition often presenting no trace of 
inflammation, although filled with pus. In some cases, how- 
ever, the cartilages are in part destroyed, the synovial mem- 
brane and ligaments eroded, without the contiguous parts 
having in any way lost their healthy characters. The same 
may be said in regard to the subcutaneous or deeper seated 
deposits of the extremities, though occasionally they are 
surrounded by ecchymosis and traces more or less evident of 
inflammation. Some patients present these deposits in various 
parts of the body at the same time, though commonly they 
will be found but in a single organ. Sometimes they exist 
in the lungs and liver without accompanying effusions on 
their serous surfaces ; in some cases there is effusion of pus 
into the cavities alone ; sometimes they are found only in the 
extremities either within or without the articulations, and in 
some instances patients are carried off with all the symptoms 
of the affection strongly marked, without any trace of these 
or other lesions being found after death — the cause of death 
in such cases being attributed by Velpeau, and it appears to 
me correctly, to the blood itself having become altered in a 
greater or less degree by the admixture of some septic poison 
which probably has its origin in the suppurating wound. 

Modern pathology has proved that these secondary deposits 
are due to small emboli which have been arrested in some of 
the smaller vessels of the tissue. It appears that usually a 
coagulation of blood takes place in the larger veins in the 
neighborhood of the injury — the clot often extending into 
the small venous radicles which arise from the bone. The 
central end of this thrombus usually undergoes softening, and 



COMPOUND FRACTURES. 197 

particles of it, being washed off* by the current of blood, are 
carried forward by the circulation, till, on entering some of 
the finer arterial capillary networks of the body {e.g. those 
of the lungs or liver), they, being too large to pass through, 
are arrested, thus causing a stasis and coagulation of blood in 
the adjacent vessels which give rise to inflammation and the 
formation of abscesses. 

As regards the treatment of these affections but little is to 
be expected from the use of any general remedies. Venesec- 
tion, at one time much resorted to on account of the supposed 
inflammatory origin of the deposits, is now justly discarded, 
all who have used it agreeing that its employment seemed 
only to hasten their development. Yelpeau, whose experience 
in this affection was large, asserts that he has seen blood- 
letting employed, either in his own practice or that of others, 
in a large number of cases, and in a good proportion carried 
as far as prudence would allow, without having ever observed 
any good effects from it. Dupuytren was favorable to the use 
of blisters ; if used they should be large and applied to the 
legs, thighs, abdomen, or chest. Moderate purging and the 
use of diuretic tisans are thought to be of some efficacy. 
Tonics and stimulants should be employed freely, and a 
nutritious diet always allowed. The local treatment of a 
wound, when symptoms of these secondary abscesses are 
threatening, or set in, is of great importance : a free exit 
should be made for any discharging matter, and the dressings 
should be light and frequently changed. If the discharge 
has greatly diminished in quantity, poultices or the warm 
water dressing should be applied with the view of determin- 
ing the fluids towards the wound. The application of a 
roller from the wound towards the trunk is highly lauded by 
some. Yelpeau asserts that of all the local measures em- 
ployed there is none in which he has as much confidence as 
this if applied before the pus has been carried in any quantity 
into the circulation, as we thereby cut off the poison and 
give the vital powers a chance of overcoming the malady. 

The prevention of these purulent deposits, however, must 
be our great aim, and in this I believe much may be done by 



198 CONTRIBUTIONS TO PRACTICAL SURGERY. 

frequent renewal of dressings, and making in all cases open- 
ings for the escape of matter. The removal of patients likely 
to be seized with the affection from crowded wards to private 
airy rooms, is a powerful prophylactic means, and in seasons 
when purulent absorptions seem rife, as they sometimes do> 
should never be neglected by the hospital surgeon. They 
sometimes follow rapidly upon the employment of debilitating 
remedies, and the early use of a good diet after operations 
and severe injuries, and abstaining from all depletory treat- 
ment when pus is freely secreted, or even when about to form, 
and the liberal use of quinia or other tonics, appears also to 
have a good effect in preventing them. 

Constitutional treatment. — Although in the majority of cases 
the constitutional treatment of compound fractures is simple, 
yet too much attention cannot be directed to it, and the greater 
success of one surgeon over another in the treatment of them 
in a great measure depends upon the attention paid to the 
general treatment. When the accident is severe, the fever 
following it is often considerable and apparently calling for 
bloodletting, though experience shows that where this is car- 
ried to any extent they rarely do well. This is indeed what 
might have been expected, the system having received a 
severe shock by the injury, which will require all its energies, 
and at times all the support that can be given to it, to aid in 
the process of restoration. Diaphoretics, such as the neutral 
or effervescent mixture, sweet spirits of nitre, small doses of 
Dover's powder, etc., combined with tepid spongings of the 
surface of the body, and local bloodletting where determina- 
tions to particular organs occur, will in general be found all- 
sufficient in the treatment. 

When cathartics are demanded, such should be chosen as 
produce their full effect speedily, in order that the patient need 
not be often disturbed by their operation, which always, even 
when fracture-beds are made use of, is attended with more or 
less disturbance of the fractured extremity. During the treat- 
ment, repeated purging is to be avoided : daily stools are not 
necessary to the comfort of the patient, though costiveness is 
to be avoided, and this end may generally be attained by 



COMPOUND FRACTURES. 199 

attention to diet alone; where, however, we fail by this means, 
the use of laxative enemata, as occasioning less disturbance of 
the body, will be preferable to the internal use of medicine. 
Sir A. Cooper asserts, that he has often seen patients des- 
troyed by the frequent administration of purges in compound 
fractures. 1 

Anodynes. — Great benefit will be found to follow the free 
use of anodynes immediately after the occurrence of the acci- 
dent, and their continuance, as well for the purpose of pro- 
curing sleep as of assuaging pain and quieting the mind, is 
always proper. Long observation in hospitals has so con- 
vinced me of the beneficial effects of anodynes after severe 
injuries, that I cannot too strongly recommend their judicious 
employment. No theoretical considerations should interfere 
with their use, and when fever is present, they may be bene- 
ficially combined with diaphoretics. Strict attention to clean- 
liness and proper ventilation of the apartment are highly im- 
portant in these accidents, and benefit is often derived from 
sending the patient into the open air on a wheeled chair, or 
other appropriate conveyance, with the limb properly sup- 
ported by splints or other apparatus, in the after stages of the 
treatment, particularly where the appetite is languishing, or 
the general health is in any way suffering from confinement. 
As after other severe injuries, very great improvement in the 
constitutional symptoms will be found to follow attention to 
the state of the skin and secretions. Where the tongue is 
furred, and the secretory organs sluggish in their functions, 
small portions of blue mass, or hydrargyri cum creta, may be 
sometimes advantageously employed, and careful sponging of 
the injured limb or of the whole body, where the skin is harsh 
and dry, is both beneficial and comforting to the sufferer. 

Diet. — When the inflammatory symptoms which set in after 
compound fractures have subsided, a good diet with animal 
food of easy digestion is proper, and where a large discharge 
of pus from the wound or hectic symptoms supervene, a full 
and nourishing one, with porter, wine, or other stimulus, 

1 On Fractures and Dislocations, 1842, p. 266. 



200 CONTRIBUTIONS TO PRACTICAL SURGERY. 

should be allowed. The influence of low living upon the 
parts interested in compound fractures has been noticed by all 
surgeons, and the improvement as well in the local as the 
general symptoms, produced by an augmented diet and the 
allowance of a stimulant, have been often observed. 

Long continuance in the supine position oftentimes exerts a 
decidedly bad effect upon the system. In elderly persons, or 
those loaded with fat, it gives rise, as has been already noticed, 
to excoriations and ulceration, and even in robust individuals 
it has been thought with some show of reason to favor the 
occurrence of engorgements, inflammations, and deposits of 
pus in the thoracic viscera. These ill consequences may be 
obviated, and the sufferer in every way much comforted after 
the inflammatory period has passed, by daily elevating the 
trunk with the aid of pillows, or a bed chair, at the same time 
taking proper precautions to prevent any disturbance of the 
extremity. 

Period of union. — Under favorable circumstances consoli- 
dation occurs to such a degree as to permit of the employment 
of crutches after compound fracture, from two to four months, 
though a long time sometimes elapses after this, however well 
the limb may have been treated, before much weight can be 
borne upon it. In many cases the consolidation is retarded 
long after the time mentioned by the presence of extraneous 
bodies, or of necrosed portions of bone. Where these exist, 
cicatrization of the wound is delayed, or if this has become 
closed, fistulous openings are formed conducting to the foreign 
body. 

The existence of diseased bone becoming loose may very 
generally be suspected from the appearance of the soft parts 
around the wound alone, fungous growths being observed to 
shoot out luxuriantly from it, and a disposition noticed in the 
surrounding parts to inflame or slough, at the same time that 
the discharge becomes thinner and more fetid. The exfolia- 
tion of bone it was formerly thought might be hastened by 
various topical applications, but practical men have long since 
been convinced of their inutility. When it becomes evident 
that a portion of bone must exfoliate, the mildest dressings 



COMPOUND FRACTURES. 201 

combined with attention to cleanliness and the state of the 
digestive functions, and occasional moderate handling of the 
dead part by means of the forceps or probe, with a view of 
gently exciting the vessels engaged in the process of removal, 
is all that is demanded in the treatment. We must wait pa- 
tiently till the necrosed portion is loosened, and as soon as 
this happens its removal is to be effected, after which the 
openings usually close up and consolidation rapidly advances. 
In one of the last cases of this kind which I saw at the Penn- 
sylvania Hospital, I removed in the month of March two 
inches of the necrosed shaft of the femur where firm union 
was evidently delayed by it. The accident had happened three 
months previously, and the patient, whose wound had cica- 
trized with the -exception of a small fistulous orifice leading to 
the bone, had a most excellent limb. As soon as the necrosed 
piece was found to have become loose, I cut down upon and 
removed it, and the treatment with the straight splints, which 
were used on the occasion, was continued. One month after 
this was done the wound had closed and the bone united, and 
about the middle of June the patient was discharged, walking 
well with a firm and good limb. 

Sometimes pieces become detached, but cannot readily be 
seized with the forceps, and here the introduction of a seton 
has been recommended, more particularly in gunshot frac- 
tures, to hasten their removal, but as its introduction is pain- 
ful, and not unfrequently gives rise to erysipelas, the careful 
use of the knife and forceps is always a preferable means. 
In all these cases, if union has not occurred the extremity is 
to be as carefully attended to, in regard to position and 
support, as in the early stages of the treatment. Where the 
portions of bone are not yet loose, and the bond of union is 
sufficiently advanced to permit of its employment, benefit 
will at times be found to arise from allowing moderate use of 
the limb, as by this means the general health is improved, 
the action of the capillaries and absorbents increased, and 
exfoliation of dead bone greatly hastened. 

Cases requiring secondary amputation. — Despite the employ- 
ment of the most cautious judgment in determining upon the 
14 



202 CONTRIBUTIONS TO PRACTICAL SURGERY. 

cases of compound fractures in which attempts are proper to 
save a limb, or of all the care which even those most thor- 
oughly versed in the treatment of these accidents can give to 
them, instances often occur, particularly in hospital practice, 
where amputation is ultimately demanded. This step may 
become necessary very soon after the accident from the 
occurrence of gangrene, and where this takes place a question 
has arisen, whether we are to amputate on its appearance, or 
are to wait till its progress be arrested, and a well-defined 
line of separation formed between the living and mortified 
parts. This important question is well settled in cases of 
mortification arising from ossification of the arteries and 
hospital gangrene, as well as in that following upon con- 
stitutional causes, the rule in these being imperative, to wait 
for the formation of this line, and were it not followed, the 
cause still being present, the disease would continue steadily 
progressive in the stump. In traumatic gangrene, however, 
the opinions of practitioners are still much divided. Curtis 1 
and Kirkland 2 long since advocated the propriety of ampu- 
tating in these cases during the progress of the gangrene. 
Larrey, who first laid down the division of gangrene into trau- 
matic and spontaneous, states, that where mortification results 
from a mechanical cause and endangers life, we need not wait 
until the disorder has ceased to spread, 3 and the more recent 
extensive experience of Lawrence, 4 Hutchison, 5 Hennen, and 
a host of others, principally military surgeons, seems to con- 
firm the propriety of it. These writers, indeed, affirm that 
traumatic gangrene, instead of contra-indicating the operation, 
rather urgently demands it ; the affection arising from a local 
injury in a healthy constitution rendering it more than likely 
that amelioration of all the symptoms "will follow the removal 
of their local cause. Mr. Guthrie, who advocates the same 
practice, urges forcibly the necessity of amputating above or 
at the point of injury, without waiting for a line of separation 
in cases of recent injury to the main artery or vein of a limb 

1 Diseases of India, p. 229. 2 Medical Surgery, vol. ii. p. 380. 

3 Military Surgery, vol. ii. 4 Med. Chirurg. Transacts., vol. vi. 

6 Practical Observations, p. 70. 



COMPOUND FRACTURES. 203 

where mortification follows, and in gangrene of a like kind, 
which sometimes ensues upon the ligature of large vessels for 
the cure of aneurisms, or suppression of hemorrhages, many 
surgeons incline to a similar practice. Mr. Pott, whose ex- 
perience in the class of accidents we are treating of was 
great, advised that amputation should never be done till nature 
has separated the diseased from the sound part, and stated 
that he had never once seen the experiment succeed; and one 
of our recent writers, Sir ffm. Fergusson, who was educated 
in the doctrines which teach the propriety of amputation in 
spreading gangrene, and was strongly prepossessed in its 
favor, says, that after having acted on and seen others re- 
peatedly do the same, he feels bound to say that the success 
has been very different from what he anticipated. In six of 
his own cases in which he operated, none succeeded. I have 
always myself waited for a line of demarcation, and as yet 
have seen nothing that would lead me to deviate from this 
practice. When amputation is determined upon in spreading 
gangrene, it should be performed without any delay, and as 
soon as the first symptoms of it become evident, as the con- 
stitutional symptoms to which it gives rise hourly augment 
in severity, and become more exhausting to the patient. The 
incisions, too, should be made in a sound part, where the skin 
is free from all discoloration, and when it can be done, a 
joint had better be interposed between the affected part and 
the point of incision. The operation, however, should never 
be practised without reference to the general symptoms, and, 
in a state of extreme prostration attended with infiltration of 
the soft parts above the seat of injury, tension of the abdomen, 
diarrhoea, delirium, or what experience has taught me to 
regard as a highly unfavorable symptom, a jaundiced tint, it 
should not be attempted. Mr. Porter of Dublin, 1 who is 
favorable to the practice and has given to the profession some 
highly interesting observations upon it, states that he is not 
aware of an instance proving fortunate where the system had 
previously been materially engaged, and in his more recent 
work on aneurism, has remarked that amputation in spread- 

1 Dublin Journ., vol. iv. p. 222. 



204 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



ing grangrene " still requires the sanction of further experience 
before it will be universally accepted." 

Hemorrhage. — This may occur from various causes, and at 
very varying periods. Where the wound has been caused by 
direct force, and is accompanied with severe contusion, the 
separation of the sloughs which necessarily follows such a 
state, sometimes gives rise to hemorrhage. Where this is 
venous, or proceeds from small and superficial vessels, it is 
attended with but little danger, being easily repressed by the 
application of dry lint or charpie to the part, accompanied 
or not by elevation of the limb, but where the blood poured 
out is from an artery of any magnitude, and is deep seated, or 
the wound is in a state of high inflammation, much difficulty 
will be found in arresting it; here pressure cannot be borne, 
the vessel if it be raised on a tenaculum, which oftentimes 
cannot be done, will not hold a ligature, or if this can be ap- 
plied, will ulcerate after a short period and give rise to a 
renewal of the bleeding. Another cause of secondary hemor- 
rhage is the pressure of a fragment of bone upon an adjoining 
artery, causing its ulceration. Bleeding from this cause, though 
much more rare, is of a more alarming kind than that just 
alluded to, the vessels opened being mostly of large size, and 
occurs at a later period than that which succeeds the separa- 
tion of sloughs. Pelletan 1 reports a case in which pressure 
of a displaced fragment of bone upon the anterior tibial artery 
caused hemorrhage so late as the seventy-fifth day to such an 
extent as to necessitate amputation. 

In both of these classes of cases, if the general and local 
symptoms be good, an effort to save the limb by securing the 
main artery is justifiable, but where the wound presents a 
bad aspect, or the patient is much exhausted, amputation 
must be at once resorted to. Hemorrhage from whatever 
eause is always an alarming occurrence to the patient, and in 
its treatment it is of much importance to give attention to his 
state of mind, he should be soothed and encouraged at the 
same time that anodynes are freely administered to produce a 



Clinique Chirurgicale, torn. ii. p. 142. 



COMPOUND FRACTURES. 205 

state of tranquillity and bodily rest. Where bleeding has 
once occurred and decided means are not at once employed to 
prevent its recurrence, the patient should be frequently visited 
by his surgeon, and closely watched by a reliable attendant. 
The dressings on the limb should be light, and great care 
taken to prevent any change of position. 

Amputation may also become necessary secondarily where 
large joints become opened by ulceration, or where life is endan- 
gered by profuse discharge and hectic, or in consequence of non- 
union of the bones. 

Despite every attention the suppuration sometimes increases 
in quantity and becomes irritating and offensive, the wound 
puts on a bad appearance, the granulations presenting a sickly 
hue, being large and ©edematous, the fractured fragments be- 
come denuded of their periosteum, of a yellowish color, or if 
the injury be near to an articulation, the ends of the bones 
become softened and carious, and the capsular ligament ulcer- 
ates; at the same time the constitution is sympathetically 
affected, the tongue grows dry and dark, the appetite fails, 
diarrhoea, profuse sweats, and hectic set in, and if the ex- 
tremity be not then removed, death usually is not slow to 
follow. Profuse suppuration alone, unaccompanied by caries 
or necrosis of the bones, rarely gives rise to a necessity for 
amputation. 

Though the reunion of bone is considerably retarded by long 
suppuration, yet the occurrence of false joint is not more 
common after compound than simple fractures. When this 
state does occur, a glance at its causes, as well as experi- 
ence, will show that amputation in the generality of cases is 
our only resource. Malposition of the fragments, the loss of 
large portions of the bone, and more than all, the presence of 
foreign matters, are the common local causes of it. The ob- 
servations of Hennen in regard to appearances on dissection 
in non-union after compound fractures are valuable. After 
stating that he had not had many opportunities of examining 
very recent cases, his experience having been chiefly confined 
to those of long-standing, he observes : " In the remainder of 
about fifty cases (two being excepted) that I have examined 



206 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



myself or been present at the examination of, and thirty 
examined by. gentlemen in whom I place the highest confi- 
dence, more or less of disease was observable in the bones, 
exclusive of the solution of continuity effected in them. The 
appearances, which were sometimes separate, but much oftener 
combined, were generally as follows : Eoughness of the ex- 
tremities of the fracture, denudation of the sides of the bones, 
and worm-eaten absorption of them ; inflammation and ulcer- 
ation; exfoliations of various sizes, and of different stages of 
looseness on the extremities of the fractured ends, but not 
often including the whole circle; the same on the sides of the 
bones in the vicinity of the fracture ; the same at a distance 
from the fracture, but not continuous with it; a line of sepa- 
ration between the bone and its epiphysis or processes very 
evidently marked, and of a vascular appearance (this last 
appearance I have seen only at the ends of the bone furthest 
from the source of circulation ; and in such cases, abscesses were 
formed over the diseased points) ; loss of the cancelli in the 
medullary cavities of the bones, with destruction of the me- 
dulla itself, or conversion of it into an offensive bloody ichor 
filling almost the entire canal ; loss of the cancelli, with a 
bloody fungus filling the medullary canal like a stopper or 
tompion ; loose adhesion of the muscles to the bones, t© such 
an extent that separation could be effected by the handle of 
a scalpel or by the finger, the whole neighborhood of the 
fractured bone of a greasy unhealthy appearance; and finally, 
necrosis or complete death of the bone, with deposition of 
new osseous matter, the deposition being irregular and evi- 
dently unhealthy, distorting the limb to a great degree." 1 

Cases are occasionally met with in which, from the neglect 
of the treatment, imprudence on the part of the patient, or 
impossibility to retain the bone in its proper place, the ex- 
tremity of the upper fragment protrudes from the wound at 
various intervals after the accident, and in these cases, re- 
duction is often impossible or impracticable to maintain, or 
the end of the bone is necrosed. In instances of this kind 
amputation has been often done, but where the general symp- 



Military Surgery, 3d ed., Lond., p. 125. 



COMPOUND FRACTURES. 207 

toms are good, and the wound otherwise is of good aspect, a 
mere difficulty in reducing the bones is no sufficient reason 
for it; resection should be resorted to, and the bone properly 
reduced. If exfoliation be waited for, a long time is neces- 
sarily required, previous to which the patient may become 
exhausted by long-continued irritation and suppuration, or if 
these did not occur, callus might be thrown out to such an 
extent around the parts, as firmly to consolidate the limb in 
the deformed position in which it would necessarily be placed 
by the protrusion. Numerous cases might be cited to show 
the safety and beneficial results attendant upon the resection 
of the protruded ends in these cases. A few examples it may 
not be amiss here to refer to. In a fracture of the upper part 
of the humerus seen by Sylvestre on the eighteenth day, one 
of the ends of the bone protruded an inch, and the other to 
the extent of half an inch. Eepeated attempts at reduction 
had been made during that time and failed. Sylvestre en- 
larged the opening, and made applications to the ends of the 
bone, with a view of hastening their exfoliation ; the superior 
one was after a time ^thrown off, and, the inferior still being 
firmly attached to the shaft, he resected it and placed the 
ends in apposition, surrounding them by proper splints. Fif- 
teen days after the operation the openings cicatrized, and in 
two months the fracture was consolidated. 1 

In 1815 M. Belair resected half an inch of the superior 
fragment of a humerus denuded of its periosteum, which had 
been fractured twenty days previously and protruded. The 
patient recovered. 2 In a case of transverse fracture of the 
tibia below its middle, Dr. Shipman resected its protruding 
end, on the twentieth day, with success. 3 In a case reported 
by Mr. Peake, a like operation was done upon the leg, three 
months after the accident, successfully, 4 and in a compound 
fracture of the femur, treated by Mr. Davidson, an inch of the 
upper shaft, which protruded through the wound, was sawed 

1 Ancien Journ. de Med., torn, xxxix. p. 275. 

2 Velpeau, Med. Operat., torn. ii. 

3 Amer. Journ. Med. Sci., vol. iii. N. S. 

4 Edin. Med. and Surg. Journ., vol. ii. p. 94. 



208 CONTRIBUTIONS TO PRACTICAL SURGERY. 

off thirty-eight days after the receipt of the injury, and the 
limb saved. 

Anchylosis, both true and false, sometimes follows the treat- 
ment of fractures. The first, or bony anchylosis, is rarely seen, 
and can only arise where the fracture either affects a joint, or 
has occurred in its immediate vicinity, in which cases the 
osseous matter thrown out is sometimes in such large quantity 
as more or less completely to surround and firmly unite the 
articulating extremities. False anchylosis is produced by the 
diminished secretion of synovia, and rigidity in the muscles, 
ligaments, and other soft parts about the joints, consequent 
upon the long-continued application of the apparatus employed, 
with the limb in the same position, and necessarily occurs, to 
a greater or less degree, after the treatment of fractures, even 
when these are situated at a distance from the joints. During 
the treatment much may be done to prevent the occurrence 
of false anchylosis by the careful employment of some degree 
of passive motion at the joint every second or third day, and, 
after its consolidation, the use of frictions, the warm douche, 
or fomentations combined with gentle exercise, will materially 
aid in the removal of the stiffness still remaining. 

As has been mentioned, it commonly happens where com- 
plete necrosis of a portion of the fractured bone occurs, that 
the sequestrum becomes loose, and is either soon thrown off, 
or is easily removed with forceps; sometimes, however, in 
young and robust patients, where the separation is long in 
being effected, so much callus may be deposited as completely 
to surround these portions, and though the limb becomes suffi- 
ciently firm to allow of some use, a continual discharge and 
irritation is kept up. In cases of this kind the callus is usually 
irregular in form and in great abundance, and the extremity 
is more or less deformed and shortened; all means' to heal up 
the fistulous openings fail, and the introduction of a probe 
usually conducts at once to the dead bone. Where the 
sequestrum is so surrounded by callus as to prevent its 
removal through the openings which exist in the new case, 
and it is ascertained to be completely loose, recourse should 
be had to operative means for the purpose of removing it. 



COMPOUND FRACTURES. 209 

To effect this, the osseous shell is to be exposed, and a portion 
of it sufficient to allow of its easy extraction removed either 
by the application of a trephine or saw, after which the sides 
of the wound are to be drawn together, and immediate union 
encouraged. 

A case, showing strikingly the bad effects of allowing these 
portions of bone to remain, has been reported from the Haslar 
Hospital. 1 After a compound fracture of a femur, union suffi- 
ciently firm to allow of free use of the limb occurred, yet 
necrosis was present and portions of the bone were occasion- 
ally discharged through the openings which still existed. In 
this state, while the patient was mounting a ladder, very pro- 
fuse hemorrhage took place in consequence of pressure of a 
portion of the bone upon the femoral artery, and necessitated 
the application of a ligature to that vessel. 

In the cases of necrosis in which extraction of the seques- 
trum is impossible, as also in such of these accidents as are 
followed by caries, diseased joints, deformed and atrophied 
limbs, and those subject to constant ulcerations, etc., amputa- 
tion is sometimes demanded by the patient, and in every such 
instance the surgeon must determine by a careful examination 
of each individual case, whether the extent of disease, pain, 
incapacity for business, and inconvenience suffered, are suffi- 
cient to call for a resort to this extreme measure. He is to 
remember that amputation is always a serious operation, and 
that when performed " par complaisance," it is peculiarly 
noted for its fatalit} 7 ; besides which the remote effects of the 
loss of a limb, in the great majority of instances, among the 
laboring classes of the community — the intemperate, beggared, 
and helpless situation to which those who submit to it so 
often sink — afford another, and to the philanthropic surgeon, 
a strong argument for the utmost caution in recommending 
amputation. Notwithstanding this, however, and the truth 
admitted by all, that to save one limb is infinitely more- 
honorable to the surgeon than to have performed numerous 
successful amputations, still the quaint remark, that "it is 
better to live with three limbs than die with four," must 
never be forgotten by him. 

1 Med.-Cliirurg. Rev., vol. viii., 1814. 



210 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



STATISTICAL ACCOUNT OF THE CASES OF AMPUTATION 

PERFORMED AT THE PENNSYLVANIA HOSPITAL 

FROM JAN. 1, 1850, TO JAN. 1, 1860, 

WITH A GENERAL SUMMARY OF THE MORTALITY FOLLOWING THIS 
OPERATION IN THAT INSTITUTION FOR THIRTY YEARS. 



In tlie22d, 26th, and 28th volumes of the American Journal 
of the Medical Sciences, I published statistical tables of all of 
the capital amputations performed at the Pennsylvania Hos- 
pital during the twenty years from January, 1830, to January, 
1850, with the view of showing the mortality following these 
operations. I now give a continuation of these statistical 
tables carried on for another ten years, viz., to January, 1860, 
drawn up in a manner similar to those already published, with 
a summary appended of the thirty years' experience of our 
Institution in this class of cases. 

In the tables, all amputations in which the operation was 
performed within twenty-four hours after the occurrence of 
the accident are included under the head of -immediate, and 
the cases treated of this class were generally of the most des- 
perate kind, resulting from railroad accidents, machinery, etc., 
where the soft parts were as seriously injured as the bones. 



AMPUTATIONS AT THE PENNSYLVANIA HOSPITAL. 



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Dec. 20th, 1852. 
Jan. 31st, 1853. 
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AMPUTATIONS AT THE PENNSYLVANIA HOSPITAL. 219 

From the above table it will be seen that from January, 
1850, to January, 1860, there were 228 capital amputations 
performed. Of these, 173 were cured and 55 died. 

Forty-three were of the thigh, seventy of the leg, eight of 
the feet, six at the shoulder-joint, thirty-eight of the arm, 
fifty -two of the forearm, eight at the wrist-joint, two of the 
hand, and one at the elbow-joint. 

One hundred and forty-six of the 228 operations were pri- 
mary, being done for recent injuries within twenty-four hours 
after the occurrence of the accident, and of these 119 were 
cured, and 27 died; 42 were secondary, of which 27 were 
cured, and 15 died ; 40 were for the cure of chronic affections, 
of which 27 were cured and 13 died. 

Twenty-five of the whole number in the table were done at 
the joints, of which 23 were cured and 2 died. 

One hundred and seven of the amputations were of the 
upper extremity, of which 94 were cured and 13 died. 

One hundred and twenty-one were of the lower extremity, 
of which 85 were cured and 36 died. 

In adding the results furnished in the above ten years to 
those given in the volumes of the American Journal already 
referred to, for the twenty years previously, we arrive at the 
following results: — 

Of 428 amputations upon 424 patients, performed during 
the thirty years from 1830 to 1860, 321 were cured and 103 
died. Of these, 261 were primary, of which 54 died ; 83 were 
secondary, of which 31 died ; 84 were for the cure of chronic 
diseases, of which 18 died. 

One hundred and ninety-four of the amputations were of 
the upper extremity, of which 21 died ; 234 were of the lower 
extremity, of which 74 died ; 46 were amputations at the 
joints, of which 6 died. 

One hundred and eighteen of the patients operated on were 
under 20 years of age, of whom 108 were cured and 10 died ; 
133 were between 20 and 30, of whom 101 were cured and 32 
died ; 87 were between 30 and 40, of whom 60 were cured and 
27 died; 62 were between 40 and 50, of whom 40 were cured 
and 22 died ; 21 were upwards of 50, of whom 16 were cured 
and 5 died. 



220 CONTRIBUTIONS TO PRACTICAL SURGERY. 



STATISTICS OF THE MORTALITY FOLLOWING THE LIGATURE 

OF ARTERIES. 

The subjects of aneurism and of hemorrhage are of the 
highest interest and importance, and are justly pointed to by 
the surgeon, as well to show the proficiency of his art, as the 
benefits conferred by it upon the human family. Notwith- 
standing, however, the great improvements made in the sur- 
gical treatment of these affections, the mortality attendant 
upon the tying of large vessels is still great. Some years 
since (1845-'49), I published the following tables comprising 
all the then fully reported cases of ligatures of the subclavian, 
iliac, carotid, and femoral vessels within my reach, and sub- 
jected them to analysis in regard to some of the difficulties of 
these operations, the mortality following them, mistakes in 
diagnosis, accidents, and the causes of death. In these tables, 
as in all such, the actual results are, I have no doubt, less 
favorable than they appear to be, unfortunate operations 
being, as is well known, less generally reported than success- 
ful ones, and in those recorded, any one who attempts to col- 
lect materials of a similar character to those here presented, 
will have often to lament, that the comparatively unimportant 
steps of the procedure are given and commented upon with 
minuteness, while the dangers attendant upon it, the difficul- 
ties of diagnosis, and post-mortem appearances, are either passed 
slightingly over, or altogether omitted. 






MORTALITY FOLLOWING LIGATURE OF ARTERIES. 221 

The succeeding table, exhibiting the mortality following the 
operation of tying the subclavian artery, includes sixty-nine 
cases, and embraces those in which the ligature was applied 
below the clavicle, as well as those in which the artery was 
exposed within the scaleni muscles, either for the arrest of 
hemorrhage, or for the cure of disease. 



222 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



I. Mortality following the Operation of 



No. 

I 1 

2 

3 

4 J 

5 
6 
7 
8 
9 

10 
11 
12 



Surgeon. 



13 
14 

15 
16 

17 

18 

19 
20 
21 

22 
23 



Keate 
Ramsden 

TV. Blizard 
Colles 

Colles 

Chamber- 

laine 
T. Blizard 

Post 

Wells 

Dupuytren 

Liston 

Mayo 



Todd 
Key 

Gibbs 
Travers 

Baroni 
Brodie 

Bullen 
Key 
Gal tie 



Sex. 



Age. 



M. 
M. 

M.' 
M. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 



M. 



M. 
M. 

M. 
M. 

M. 

M. 
M. 



Wishart M. 
Arendt M. 



Right or 
left side. 



25 
32 

Old 
33 

48 

25 

47 

27 

61 

37 

35 

38 



35 

35 
73 

56 

60 

36 



47 
30 



Right side 



Right side 
Right side 
Left side 
Left side 
Left side 
Right side 
Left side 
Left side 
Left side 



Right side 



Left side 

Right side 
Right side 



Left side 
Right side 



Disease. 



Duration 
ofdisease. 



Aneurism 
Aneurism 

Aneurism 
Aneurism 

Aneurism 

Aneurism from wound 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 



4 months 



Aneurism 
Aneurism 

Aneurism 
Aneurism 

Wounded axillary 
Aneurism 

Aneurism 
Aneurism 

Hemorrhage following 
compound fracture of 
superior end of hu 
merus. 

Aneurism 

Aneurism 



2 months 

6 weeks 

3 months 
1 month 

3 weeks 

7 months 
7 years 

5 months 

4 months 



4 months 



Some days 

after 
2 months 



4 months 
6 weeks 



3 weeks 
1 month 



Ligature 
separated. 



13th day 



18th day 
22d day 
15th day 
12th day 



12th day 



12th day 



19th day 
12th day 



16th day 
16 th day 



1 The ligature was here placed below tbe clavicle. 

3 The ligature was here placed internally to the scalenus muscle. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



223 



Tying the Subclavian Artery. 



Date of 
operation. 

March, 1800 

Nov. 9th, 1809 

1811 
Oct. 10th, 1811 

July 16th, 1813 

Jan. 17th, 1815 

Jan. 10th, 1815 

Sept. 8th, 1817 

April 12th, 1818 

March 7th, 1819 

April 3d, 1820 

March 19th, 1821 



Feb. 8th, 1822 


Cured 


1822 


Died 


Jan. 5th, 1823 


Cured 


Jan. 17th, 1823 


Died 


Jan 17th, 1823 


Cured 


March 7th, 1823 


Died 


April 3d, 1823 


Cured 


Sept. 20th, 1823 


Cured 


1823 


Died 



Result. 



Cured 
Died 

Died 
Died 

Died 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Died 



August 23d, 1823 Cured 



June 6th, 1826 



Cured 



Period of 
death. 



5th day 

4th day 
4th day 

3d day 
8th day 



12th day 



7th day 



3d day 



6 th day 



3d day 



Cause of death. 



Irritation from 
sloughing of 
tumor 
Not stated 
Hemorrhage 

Mortification of 
limb 



Gangrene of 
hand and arm 



Inflammation 
of sac and 
pleura ; had 
hemorrhage 
on the 8th, 
9th, 10th, 

and 11th days 
after opera- 
tion 



Inflammation of 
sac, pleura, 
and pericar- 
dium. 



Inflammation 
of cavity of 
chest 



Gangrene 



Exhaustion 



Work. 



London Med. Rev., vol. 

vi., 1801. 
Practical Observations. 



Hodgson on the Arteries. 
Edinburgh Med. and Surg. 

Journ., vol. xi. 
Edinburgh Med. and Surg. 

Journ., vol. xi. 
Med. Chirurg. Transacts., 

ix. 
Hodgson on the Arteries. 

Med. Chirurg. Transacts., 

vol. ix. 
Amer. Journ. of Med. Sci., 

vols. iii. and xiii. 
Edinburgh Med. and Surg. 

Journ., vols. xv. & xvi. 
Edinburgh Med. and Surg. 

Journ., vol. xvi. 
Med. Chirurg. Transacts., 

vol. xii. 



Dublin Hospital Reports., 

vol. iii. 
Med. Chirurg. Transacts., 

vol. xiii. 



Med. Chirurg. Transacts., 

vol. xii. 
Med. Chirurg. Rev., vol. 



Gazette Medicale, No. 
xliv., 1835. 

London Med. and Phys. 
Journ., vol. ii., New Se- 
ries, 1827. 

London Med. Repository, 
vol. xx. 

Med. Chirurg. Transacts., 
vol. xiii. 

Chir. Clin, of Delpech, 
torn. i. 



Edinburgh Med. and Surg. 

Journ., vol. xxi. 
London Med. and Phys. 

Journ., vol. ii., N. S. 



224 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 


Surgeon. 


Sex. 


Age. 


Right or 
left side. 


Disease. 


Duration 

of disease. 


Ligature 
separated. 


24 


Liston 
Thorpe 
B. Cooper 
Gibson 

Balardini 

Dupuytren 
Porter 

Baker 

Crossing 

Mott 

Bland 

Buchanan 

Mayo 

Fergusson 

Mott 

Porter 
Brodie 

Lallemand 

Auchinloss 

Nicol 

Nichols 

Segond 

Lizars 
Blasius 

Haspel 

H oh art 

Earle 

Hayden 

Catanoso 

Suetin 


M. 
M. 
M. 
M. 

F 

M. 
M. 

F. 

M. 

M. 

M. 

M. 

M. 

M. 

F. 

M. 
M. 

M. 

M. 

M. 

F. 

F. 

F. 
M. 

M. 

M. 

M. 

F. 

M. 

M. 


43 
36 
38 
35 

50 

40 
40 

18 

46 

28 

63 

55 

49 

60 

21 

63 
56 

65 
68 
21 
40 
42 

38 

57 
33 

44 


Right side 
Right side 
Right side 
Left side 

Right side 

Right side 
Left side 

Right side 

Right side 

Right side 

Right side 

Right side 

Left side 

Right side 

Right side 

Left side 
Right side 

Right side 

Left side 

Left side 

Left side 


Aneurism 
Aneurism 
Aneurism 

Ruptured axillary, from 
attempts to reduce a 
luxation 

Aneurism 

Aneurism 
Aneurism 

Tumor around head of 
humerus mistaken for 
aneurism 

Aneurism 

Aneurism 

Aneurism 

Secondary hemorrhage 

after amputation 
Aneurism 

Aneurism 

Aneurism 

Aneurism 
Aneurism 

Wounded axillary 

Aneurism 

Medullary sarcoma con- 
sidered aneurismal 
Aneurism 

Aneurism from wound 

Aneurism 
Wounded axillary 

Wounded axillary 

Aneurism 

Supposed aneurism 

Aneurism 

Wounded axillary 

Aneurism 


9 months 
Hmonths 
3 months 

2 days 

3 months 




25 
26 


13th day 


27 




28 
29 


16th day 


30 
31 


9 days 


17th day 


32 
33 
34 


13 weeks 
7 weeks 


85th day 
15th day 
43d day 


35 




36 
37 
38 l 


1 month 

2 years 

A year or 

two 
5 weeks 
11 weeks 

1 day 

18 months 

13 months 


18th day 
31st day 


39 
40 


17th day 


41 

42 


12th day 


43 




44 


21st day 
11th day 


45 


6 days 

10 years 
20th day 

Immedi- 
ately after 
4 months 


46 


Left side 


47 3 




48 






49 
50 


Right side 
Left side 
Right side 
Right side 

Left side 


22d day 
16th day 


51 1 


10 months 
14 days 


52 2 




53 


20th day 


— &— 





1 The ligature was here placed internally to the scalenus muscle. 

2 The ligature was here placed below the clavicle. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



225 



Date of 
operation. 


Result. 


Period oi 
death. 


iCause of death. 


Work. 


Sept. 14th, 1826 
June 21st, 1827 


Died 
Cured 
Died 
Died 

Died 

Died 
Cured 

Died 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Died 

Cured 
Died 

Cured 

Died 

Died 

Cured 

Cured 

Cured 
Died 

Died 

Cured 

Supposed 
cure. 
Died 

Cured 
Died 


14th day 


Hemorrhage 


Edinburgh Med. and Surg. 

Journ., vol. xxvii. 
Amer. Journ. of Med. Sci., 


Dec. 4th, 1827 
March 17th, 1828 

Nov. 4th, 1828 
June 12th 1829 


2 months 

after 
8th day 

About 1 
rao. after 
7th day 


Sloughing of 

the sac. 
Gangrene of 

hand and 

forearm. 
Suppuration of 

turaor 


vol. ii., 1828. 
Amer. Journ. of Med. Sci., 

vol. ii., 1828. 
Amer. Journ. of Med. Sci., 

vol. ii., 1828. 

Gazette Medicale, April, 

1841. 
Lancet, vol. ii., 1833—34. 


June 27th, 1829 




Dublin Hospital Reports, 

vol. v. 
Lancet, vol. ii., 1828-29. 


1829 






June 23d, 1830 






Med. Chirurg. Transacts., 

vol. xvi. 
Amer. Journ. of Med. Sci., 


August 30th, 1830 
Dec. 17th, 1830 






4th day 




vol. vii. 
Amer. Journ. of Med. Sci.. 


May 1st, 1830 
March 26th, 1831 


Gangrene of 
stump 


vol. ix. 
Glasgow Journal, vol. iii. 

Med. Chirurg. Transacts., 

vol xvi. 
Edinburgh Med. and Surg. 

Journ., vol. xxxvi. 
Amer. Journ. ofMed. Sci., 

vol. xii. 
Dublin Journal, vol. i. 


May 12th, 1831 
Sept. 22d, 1831 
Dec. 31st, 1831 


18th day 




Hemorrhage 


Dec. 13th, 1831 
Feb. 19th, 1833 


6 th day 


Inflammation 


London Medical Gazette, 
vol. ix. 


July 23d, 1833 

Jan. 16th, 1834 

April 30th, 1833 

April 5th ; 1834 

April 27th, 1834 
1834 


3d day 
25th day 


Effusion on 

brain 
Hemorrhage 


xxxvii. 

Edinburgh Med. and Surg. 

Journ., vol. xlv. 
Edinburgh Med. and Surg. 

Journ., vol. xlii. 
Amer. Journ. of Med Sci., 






vol. xii. 
Journal Hebdomadaire, 






torn, i., 1835. 
Lancet, vol. ii., 1833—34. 


2d day 

After 
some days 




Med. Chirurg. Rev., vol. 

XX. 

Gazette des Hopitaux, 

1839, p. 186. 
Edinburgh Med. and Surg. 

Journ., vol. xlv. 
Amer. Journ. of Med. Sci. , 


Feb. 4th, 1835 
May 7th, 1835 
April 14th, 1835 
Sept 15th, 1835 
September, 1835 

1835 


Mortification of 
arm 






12th day 


Hemorrhage 


vol. xviii. 
Amer. Journ. of Med. Sci., 

vol. xxi., 1837. 
Amer. Journ. of Med. Sci., 


33d day 




vol. xx., and Ann. de 
Chirurgie. 
Med. Chir. Rev., vol. xxii. 









226 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 


Surgeon. 


Sex. 


Age. 


Right or 
left side. 


Disease. 


Duration 
of disease. 


Ligature 
separated. 


54' O'Reilly 
55 Montanini 


M 


39 




Aneurism 






M. 


21 


Right side 


Aneurism from wound 


16 days 


13th day 


1 

56 Rigaud 

57 J oh erf, 


M 


31 


Right side 

Right side 
Left side 


Aneurism 




13th day 


M. 
M. 


61 
23 


Aneurism 


6 months 


58 


Synie 


Aneurism from ruptured 1 month 






axillary 






59 


White 


M. 




Left side 


Aneurism from wound 


2 weeks 


17th day 


60 


Nott 


M 


30 




Aneurism from wound 




31st day 

47th day 
12th day 
14th day 


61 
62 


Skey 

Hulton 

Gross 


M. 
M. 
M. 


35 

36 


Left side 


Aneurism 
Aneurism 
Aneurism 


2 months 

3 months 
18 months 


63 


Right side 


64 1 


Partridge 
B. Cooper 


M 


38 


Right side 
Left side 


Aneurism 


12 months 




65 


M. 


50 


Aneurism 


6 weeks 




66 


Hutin 
McDougall 

Mott 


M. 
M 


26 
?4 




Wounded axillary 
Aneurism from gunshot 

Aneurism from gunshot 

Hemorrhage after am- 
putation 


12 days 
6 weeks 




67 


Left side 




68 


M 


35 




22 days 


15th day 
27th day 


69 


A. C. Post 


M. 


37 


Right side 







1 The ligature was here placed internally to the scalenus muscle. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



227 



Date of 
operation. 



April 16th, 1836 

June 28th, 1836 

1836 

Nov. 22d, 1837 
Oct. 24th, 1837 



Sept. 17th, 1838 

Nov. 27th, 1838 

1840 
Jan. 8th, 1841 
Feb. 18th, 1841 

Feb. 20th, 1841 
May 18th, 1841 



1842 
Dec. 12th, 1841 



June 11th, 1844 
Dec. 6th, 1844 



Result. 



Died 

Cured 

Died 

Died 

Cured after 
amputation 
at shoulder- 
joint, made 
necessary 
in conse- 
quence of 
return of he 
morrhage. 
Cured 

Cured 

Cured 
Cured 
Died 



Died 
Died 



Died 
Died 



Cured 
Cured 



Period of Cause of death, 
death. 



13th day 



6 weeks 

after 
29th day 



31st day 

4th day 
15th day 



10th day 
7th day 



Hemorrhage 



Suppuration of 

tumor 
Hemorrhage 



Tumor burst in- 
to cavity of 
chest 

Pericarditis 
and pleurisy 
Pleuropneu- 
monia ; some 
hemorrhage 
day of death 
Hemorrhage 
Hemorrhage 



Work. 



Amer. Journ. of Med. Sci., 

vol. xxi., 1838. 
Gazette Medicale, vol. v., 

1837. 
Archives Generales, vol. 

xlii. 
L'Experience, vol. i., 1838. 
Edinburgh Med. and Surg. 

Journ., vol. 1. 



Amer. Journ. of Med. Sci., 

vol. xxiii. 
Amer. Journ. of Med. Sci., 

vol. ii. N. S., 1841. 
Lancet, vol. ii., 1840-41. 
Lancet, vol. ii., 1840-41. 
Western. Journ. Med. and 

Surg., June, 1841. 

London Med. Gaz., 1841. 

Guy's Hosp. Reports, No. 
xiii., 1841. 



Gazette Medicale, 1842. 
Maryland Med. and Surg. 

Journal, vol. ii., Jan. 

1841. 
New York Journ. of Med., 

vol. iv. 
New York Journ. of Med., 

vol. iv. 



228 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Mortality. — Of the sixty-nine cases iD eluded in the pre- 
ceding table, thirty-six recovered and thirty-three died. 

Sex. — Of sixty-six cases in which the sex is noted, fifty- 
nine were males and seven females. Of the seven females, 
six labored under aneurism, and one presented a tumor around 
the head of the humerus, which was mistaken for it. 

Right or left side. — Of fifty-four cases in which the affected 
side is mentioned, thirty-one were on the right and twenty- 
three on the left side. 

Age. — This is given in fifty-nine of the cases, of which 
number there were — 



Under 20 


. 1 


Between 20 and 30 


. 10 


" 30 and 40 


. 22 


" 40 and 50 


. 11 


" 50 and 60 


. 6 


" 60 and 70 


'. . . 8 


Above 70 . 


. 1 



Disease or injury. — Of the sixty-nine cases of operations 
mentioned in the table — fifty-six were done for the cure of 
aneurism — nine in consequence of wounds or secondary 
hemorrhages — one was made necessary in consequence of 
rupture of the axillary in an attempt to reduce an old luxation, 
and three were done for diseases supposed to be aneurismal. 

Period the ligature separated. — In thirty-five of the cases in 
which it has been noted, the ligature came away — in one, on 
the eleventh day ; in six, on the twelfth ; in four, on the thir- 
teenth; in one, on the fourteenth ; in three, on the fifteenth ; 
in four, on the sixteenth ; in three, on the seventeenth ; in 
two, on the eighteenth; in one, on the nineteenth; in one, on 
the twentieth; in one, on the twenty-first; in two, on the 
twenty-second; in one, on the twenty-seventh ; in two, on the 
thirty-first; in one, on the forty-third; in one, on the forty- 
seventh; and in one, on the eighty-fifth. 

Return of 'pulsation in the tumor after the application of the 
ligature. — In three of the sixty-nine cases, pulsation returned 
in the aneurismal tumor after the operation. In one of these 
(No. 12) it was discovered thirty hours after the operation, 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 229 

and the patient died after repeated hemorrhages. In the 
second case (No. 11) it was noticed the day after the operation, 
and disappeared in two days, the patient recovering, and in 
the third instance (No. 60) it was observed two days after the 
operation, and at the end of forty days was still strong, though 
ultimately the disease was cured. 

Hemorrhage after the operation. — With three exceptions, all 
the cases in which secondary hemorrhage followed the opera- 
tion proved fatal. In two of these (Nos. 19 and 52) it oc- 
curred before the separation of the ligature, on the sixteenth 
and nineteenth days, and, in the third case (No. 37), it came 
on on the fourth and fifth days after the ligature had been 
cut off. 

Bursting of the tumor. — In six cases the tumor is stated to 
have suppurated, and either to have been opened or to have 
burst externally after the operation. Of these, four were 
cured (Nos. 8, 30, 37, and 62) and two died. In two of them 
the suppuration did not occur till about the seventh week 
after the operation, and both of these did well. 

In two of the cases in the table, the contents of the tumor 
were discharged through the lungs, this termination in one case 
being followed by restoration to health, and in the other by 
death. The operation in the first of these (No. 19) was done 
on the third of April, and on the 21st, the tumor began to 
increase, and was evidently suppurating. On the 29th, six 
or eight ounces of bloody pus were brought up during a par- 
oxysm of coughing, and the tumor suddenly diminished to 
one-half its size. It was now punctured, and five ounces 
of the same kind of matter was discharged, to the great relief 
of the patient. A cavity could now be distinctly felt between 
the 1st and 2d ribs at their sternal ends, through which the 
fluid had passed into the lungs, and there being a free com- 
munication, the air passed into the sac whenever he coughed, 
which distended it, and sometimes escaped by the external 
opening. The discharge from the outer opening gradually 
lessened, and, at the end of three weeks, ceased. His cough 
slowly wore off, and ninety-two days after the operation the 
patient was quite well. 



230 CONTRIBUTIONS TO PRACTICAL SURGERY. 

In the second of these interesting cases (No. 63), the ope- 
ration was done by our countryman, Dr. Gross, on the 18th 
of February. After its performance, the contents of the 
tumor became solidified, and its volume progressively dimin- 
ished. On the 15th of March, the patient suffered from fever, 
and a slight degree of tenderness on the apex of the tumor 
was observed. On the 16th, he was suddenly seized with in- 
tense pain in the chest, which was particularly severe at the 
base of the right lung, and extended up towards the axilla. 
The respiration throughout the right lung was bronchial, and 
there was dulness on percussion over the'lower ribs; the 
aneurismal tumor had suddenly disappeared at the time of the 
attack. On the 18th, the patient experienced a sensation as 
if a fluid was passing from the pleuritic cavity into that of the 
aneurismal tumor, and, upon auscultation, a plashing sound 
was heard at every inspiration, the noise resembling that pro- 
duced by shaking water in a closed vessel. On the 20th, he 
died. Upon dissection, the aneurismal tumor was found to 
communicate by an aperture, one inch and three-quarters in 
length by an inch and a half in width, with the pleuritic cavity ; 
it was situated between the first and second ribs, and was ob- 
viously the result of ulcerative absorption, induced by pres- 
sure of the tumor. Both ribs were denuded of their perios- 
teum. The right side of the chest contained nearly three 
quarts of bloody serum, intermixed with laminated clots and 
flakes of lymph, the former of which had evidently been 
lodged originally in the aneurismal sac. 

The discharge of the contents of a subclavian or axillary 
aneurism into the lung is a rare termination of it, and, in con- 
nection with the two cases given, it may be well to notice one 
somewhat similar, which has been recorded by M. Neret, of 
Nancy. The patient, aged 38, was admitted into the hospital 
St. Charles for haemoptysis, and was found to labor 'under an 
aneurism of the left subclavian, of the size of a large chestnut, 
which had existed about eight months. He died a short time 
after his admission, and on dissection, the aneurism was found 
communicating with a cavity in the upper part of the lung, 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 231 

of the size of the head of a new-born infant. A case of a simi- 
lar kind is related in his work on the arteries by Mr. Guthrie. 

Cause of death. — Of the sixty-nine cases, thirty-three, or 
nearly one-half, died. Of these, two died from sloughing of 
the tumor; nine, from hemorrhage coming on at various 
periods between the fourth and thirty-third days; five, from 
inflammation within the chest; six, from mortification of the 
extremity; one, from effusion on the brain; one, from exhaus- 
tion; one, from inflammation; three, from suppuration of the 
tumor; and in five cases the cause of death is not given. 

Mistakes in diagnosis. — In two of the cases contained in the 
table, the aneurisms had been mistaken for abscesses, and 
punctured previous to the operation. In three other cases, 
malignant tumors about the shoulder were looked upon as 
aneurisms. The first of these cases (No. 31) was that of a 
female, aged eighteen, operated upon in the New Castle In- 
firmary, England. It proved to be a fungus nematodes. It 
became less in size after ligature of the vessel, but speedily 
assumed a serious aspect, and soon terminated her existence. 
The artery was found obliterated for at least one inch. In 
No. 43, the true nature of the affection was a medullary sar- 
coma of the upper part of the humerus. In the third of these 
cases (No. 50), the artery was taken up in April, 1835, and the 
aneurism supposed to be cured. On the 2d of July of the 
same year, the patient died of dropsy, and on dissection it 
became evident that no aneurism had ever existed. The 
tumor was of a dense structure and lying over the artery. 

Difficulties of the operation. — These need not here be dwelt 
upon — every practical surgeon must be aware that at times 
they must be very great. Our only object at present is to 
call attention to the fact, that some of the most celebrated 
operators have failed in their efforts to pass a ligature around 
the subclavian. In a case at Guy's Hospital, Sir Astley Cooper 
attempted to tie the vessel above the clavicle. The aneurism 
was very large, and the clavicle thrust upwards by the tumor 
so as to make it impossible to pass a ligature under the artery 
without incurring the risk of including some of the nerves of 



232 CONTRIBUTIONS TO PRACTICAL SURGERY. 

the axillary pl.exus. The attempt was, therefore, abandoned. 
In a case of large aneurism of the right side, of four years' 
standing, which occurred to M. Dupuytren, in 1819, he suc- 
ceeded, as he believed, after one hour and forty-eight minutes, 
in placing a ligature around the subclavian from above the 
clavicle. Pulsation in the tumor continued after the opera- 
tion, which M. Dupuyten stated to have been the most tedious, 
difficult, and painful that he had ever attempted, and after 
death, which occurred on the ninth day, the ligature was 
found knotted loosely on that portion of the fourth cervical, 
which afterwards becomes the external cutaneous or musculo- 
cutaneous nerve, and the artery was not included in the 
ligature. 

In the case of a soldier, aged 27, with hemorrhage from 
the armpit, resulting from a wound received in a duel, Prof. 
Lallemand attempted, without success, to place a ligature 
upon the subclavian from above the clavicle. The hemor- 
rhage was arrested by ligature of the wounded vessel, and he 
lived till the following day. In a case of aneurism which 
occurred to Mr. Cusack, of Dublin, he attempted to place a 
ligature on the subclavian in its third stage, and in endeavor- 
ing to pass it, the aneurism was penetrated. An alarming 
gush of blood followed, which was arrested by plugging up 
the wound; the man survived ten days, dying of hemorrhage. 

In one case included in our table (No. 16), the sac was 
accidentally punctured by the needle in the attempt to pass 
it beneath the vessel, and gave rise to "terrific hemorrhage." 
Even after the ligature was secured, the bleeding was not 
checked till a sponge tent in the wound, and pressure, were 
applied. 

In No. 11 (which, by the way, was the first successful ope- 
ration for axillary aneurism in Great Britain), the inferior 
nervous band, passing out to form the axillary plexus, was 
surrounded by the ligature instead of the artery; the mistake, 
however, was soon discovered; and the ligature, still retained, 
was used to pull the nerve a little upwards from its situation, 
so as to admit of the more ready exposure and deligation of 
the artery. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 233 

In cases of great difficulty of passing the ligature around 
the artery, it has been proposed by Mr. Hargrave and M. 
Cruveilhier to saw through or excise a portion of the clavicle 
— a procedure we should suppose which would greatly tend 
to increase the danger of the operation. 



16 



234 



CONTRIBUTIONS TO PRACTICAL SURGERY. 

II. Mortality Following the Operation of 



No. 

1 
2 
3 



Surgeon 



Abernethy 
Abernethy 
Abernethy 



Sex. 



Age. 



Right or 
left side. 



4 Freer 

5 'Abernethy 

6 Tomlinson 



Groodlad 
Dorsey 
A. Cooper 
Delaporte 
A. Cooper 
A. Cooper 



9 
10 
11 
12 



13 Ramsden 
14. Albert 

15 Bouchet 

16 A. Cooper 

17 :Brodie 



18 
19 
20 
21 
22 
23 
24 

25 

26 

27 



Norman 

Mackesy 

Post 

Lawrence 

Whit- 
bridge 
New- 
bigging 
Delpech 

Moulaud 



H. Cline 



28 iSoden 



29 
30 



Collier 
Dupuytren 



Disease. 



34 Rightside 

i 
40 Left side 



40 

27 
40 
40 

41 

30 

89 

60 

37 



75 



55 

27 

50 

50 

41 

40 

19 

30 

27 

30 
30 

56 
24 
45 



Rightside 
Rightside 
Left side 



Left side 



Left side 
Left side 

Right side 
Left side 
Rightside 

Right side 
Rightside 
Left side 



Secondary hemorrhage 
after ligature of femoral 
Aneurism 

Aneurism 

Aneurism 
Aneurism 
Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 
Aneurism 



Aneurism 

Aneurism 

Aneurism 
Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism in both groin 

and hnm 
Aneurism 

Aneurism 
Aneurism 

Aneurism 

Aneurism 

Aneurism from gunshot 

Aneurism 



Duration 
of disease. 



Ligature 
separated. 



11 weeks 

4 months 
4 months 
3 years 

2 years 

3 months 



of long 
duration 



4 years 

2 weeks 
1 year 



about the 

20th day 
about the 

12th day 
16th day 
10th day 
26th day 

16th day 

14th day 

17th day 



17th day 
17th day 



19th day 
11th day 



3£ months 13th day 
2 weeks 24th day 
16th day 



8 months 



4 months 
2 months 
14 months 



17th day 



24th day 



17th day 
16th day 



16th day 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 

Tying the Iliac Arteries. 



235 



Date of 
operation. 


Result. 


Period of Cause of death, 
death. 


Work. 


March, 1796 
October 24 
Oct. 11, 1806 


Died 

Died 

Cured 

Cured 
Cured 
Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Died 

Died 
Died 

Cured 

Cured 

Cured 
Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Died 

Cured 
Died 

Cured 

Cured 

Died 

Cured 


8th clay 
23d day 


Hemorrhage 

Sloughing of 
the sac 


Surgical Works, vol. ii., 

1825. 
Surgical Works, vol. ii. 

Surgical Works, vol. ii. 


Oct. 4, 1806 






On Aneurism. 


Feb. 25, 1809 






Surgical Works, vol. ii. 
Lond. Med. and Phys. 

Journ., vol. xviii. 
Edinburgh Med. and Surg. 

Journ., vol. viii., 1812. 
Eclectic Repertory, vol. 

ii., 1812. 
Guy's Hospital Reports, 

vol. i., 1836. 
Mems. de la Soc. Med., 

d'EmuIation, torn. vii. 
Med. Chirurg. Transacts., 

vol. iv. 
Med. Chirurg. Transacts., 

vol. iv. 

Hodgson on the Arteries, 

p. 418. 
Hodgson on the Arteries. 

Breschet's Trans, of Hodg- 


Auc. 29, 1807 






July 29, 1811 
Aug. 19, 1811 
June 22, 1808 














Jan. 3, 1810 
Aug. 24, 1810 
Feb. 14, 1811 


14th day 


Mortification of 
limb 


10 weeks 
& 6 days 

after 
3d day 

less than 
3 weeks 


Bursting of an 
aneurism of the 

aorta 
"Extreme de- 
bility" 
Mortification of 
limb, and pa- 
tient died with 
symptoms of 
tetanus 




1812 


April, 30, 1813 






son, torn, ii 
Med. Chirurg. Transacts., 

vol. iv. 
Hodgson on the Arteries. 
Med. Chirurg. Transacts., 






Sept. 13, 1813 
Oct. 18, 1813 










vol. x., 1819. 
Edinburgh Med. and Surg. 

Journ., vol. xi., 1815. 
American Med. and Phys. 

Register, vol. iv. 
Med. Chirurg. Transacts., 

vol. vi., 1815. 
New England Journ., vol. 

iv. 
Edinburgh Med. and Surg. 

Journ. vol. xii., 1S16. 
Clinique Chirurgicale, 

torn. i. p. 38. 
Casamayor on Aneurism. 
Hodgson on the Arteries, 

p. 198. 
Med. Chirurg. Transacts., 

vol. vi., 1815. 
Med. Chirurg. Transacts., 

vol. vii., 1816. 
Med. Chirurg. Transacts., 

vol. vii., 1816. 
Breschet's Trans, of Hodg- 
son, torn. ii. 


Jan. 4, 1814 






Jan. 11, 1814 






Jan. 8, 1815 
March 13, 1815 


28th day 


Mortification of 
limb 


July 2, 1815 
1815 


10th day 


Mortification of 
limb 




in 3d week 


Mortification of 
limb 




April 22, 1816 
Aug. 28, 1816 
Oct. 15, 1816 






3d day 


Moitification of 
limb 









236 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 



31 



Surgeon. 



32 

33 
34 



35 
36 

37 

38 

39 
40 

41 

42 

43 

44 

45 
46 

47 

48 
49 

50 

51 

52 

53 

54 

55 

56 



Hicks 



Norman 

Robertson 
Norman 



Cole 
Bond 

Wilmot 

Liston 

Kirby 
Todd 

N. Smith 

Todd 

Salmon 

Jameson 

Key 

Stevens 

Warren 

B. Cooper 
Arendt 

Wright 

Tait 

Tait 

Rogers 



Gibbs 
Brodie 



Sex. Age, 



M. 



M. 

M. 
M. 



M. 

M. 

M. 
M. 

M. 

F. 

M. 
M. 
M. 
M. 
M. 
M. 

M. 
M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 



50 

38 
14 



29 
31 

32 

35 

34 

22 



28 
29 

26 



49 
44 

42 

54 

54 



39 

38 



Right or 
left side. 



Right side 

Right side 
Left side 



Right side 

Left side 
Left side 

Left side 
Left side 

Right side 
Right side 

Right side 
Left side 

Left side 
Right side 
Left side 
Left side 



Left side 



Disease. 



Hemorrhage from a 
sloughing bubo 



Aneurism 



Aneurism 

Secondary hemorrhage 
from wound 



Aneurism 
Aneurism 

Aneurism 

Aneurism 

Aneurism 
Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Aneurism 

Secondary hemorrhage 

from punctured wound 

Aneurism 

Aneurism 
Aneurism 

Inguinal and popliteal 

aneurisms 
Aneurism 

Aneurism 

Aneurism 

Wounded artery 

Hemorrhage from ulcer- 
ation 
Aneurism 



Duration 
of disease. 



2 weeks 



5 weeks 



Ligature 
separated. 



12th clay 
21st day 



3 years 

5 weeks 

3 months 

5 months 

1 month 
7 months 
10 months 

6 months 
1 year 



2 weeks 

1 year 
4 months 
14 months 
4 weeks 



3 months 



19 th day 
15th day 

31st day 

16th day 

18th day 

20th day 
21st day 
21st day 

12th day 
22d day 
ISth day 



21st day 
42d day 



13th day 



MORTALITY FOLLOWING: LIGATURE OF ARTERIES. 



237 



Date of 

operation. 


Result. 


Period of 
death. 

12th day 


Cause of death. 


Work. 


Jan. 22, 1817 


Cured after 
amputation, 
made neces- 
sary in con- 
sequence of 
gangrene of 

limb 
Died 

Cured 

Cured after 
amputation, 
made neces- 
sary in con- 
sequence of 
gangrene of 

limb 
Cured 
Cured 

Cured 

Cured 

Cured 
Died 

Cured 

Died 

Cured 

Died 

Cured 

Cured 

Cured 

Died 
Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 




Hennen's Military Surg. 
1829, p. 187. 

Med. Chirurg. Transacts., 
vol. X. 

Edinburgh^Med. and Surg. 

Journ., vol. xiii., 1817. 
Med. Chirurg. Transacts., 

vol. X. 

Casamayor on Aneurism. 
Lond. Med. and Physical 

Journ., vol. iv. 
Dublin Hospital Reports, 

vol. ii., 1828. 
Edinburgh Med. and Surg. 

Journ., vol. xvi., 1820. 
Surgical Cases, p. 101. 
Dublin Hospital Reports, 

vol. iii., 1822. 


April 6, 1817 

July 24, 1817 
Aug. 27, 1817 

1817 


Peritonitis and 
sloughing of 
wound 




• 




June 6, 1818 






July 9, 1818 
Nov. 6, 1819 










Dec. 18, 1811 






June 3, 1819 
July 25, 1820 
Dec. 4, 1820 
Sept. 12, 1820 
May 6, 1821 
Sept. 28, 1822 
March 12, 1822 


15th day 


Gangrene of 
the sac 

Tetanus 


21st day 


Phys. Sci., vol. i., 1820. 
Dublin Hospital Reports, 

vol. iii., 1822. 
Med. Chirurg. Transacts., 

vol. xii., 1822. 
Philada. Med. Recorder, 

vol. v., 1822. 
Guy's Hospital Keports, 

vol. i., 1836. 
N. Y. Med. and Physical 

Journ., vol. i., 1822. 
New England Journ., vol. 

xii., 1823. 
Tyrrell's Cooper, vol. ii. 


9th day 


Mortification of 
limb 






Feb. 18, 1823 






June 21, 1823 

1824 


27th day 


Hemorrhage 


Sept. 22, 1824 
May 8, 1825 
April 16, 1826 
1826 






vol. vii., 1824. 
London Med. and Phys. 

Journ., vol. iv., 1828. 
Edinburgh Med. and Surg. 

Journ., vol. xxvi., 1824. 
Edinburgh Med. and Surg. 

Journ., vol. xxvi., 1824. 
Philada. Med. Recorder, 












Nov. 1826 






vol. ix., 1826. 
Gazette Medicale, 1833. 


Feb. 26, 1827 






p. 650. 
London Med. and Phys. 

Journ., vol. v., 1827. 
Amer. Journ. Med. Sci., 


Feb. 21, 1828 












vol. ix., 1831. 



238 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 


Surgeon. 


Sex. 

M. 
M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 
M. 

M. 

M. 

M. 

F, 

M. 

M. 

M. 

M. 

M. 

M. 

M 

M. 

M. 

M. 

M. 
M. 
F. 
M. 
M. 


Age. 

46 
63 

37 

13 

44 
16 
.35 

28 

28 
27 

40 
40 

4S 

30 

36 

35 

56 

25 

42 

23 

45 

27 

4S 

33 

39 
30 
43 

26 


Right or , Disease, 
left side. 


Duration : Ligature 
of disease, separated. 


57 

58 


Randolph 
Daniel 

Ewing 

Morrison 

Mott 

B. Cooper 

Velpeau 

Hall 

Guthrie 

Sinclair 
Guthrie 

Smith 
Laid law 

Ruan 

Me Farlane 

Mirault 

Morrison 

Warren 

Morrison 

Hobart 

Hewson 

Liston 

Lallemand 

Horner 

Medoro 

Porter 

Bulchrens 

Portal 

Dickson 

Mouret 

Petrunti 


Right side Aneurism 
Right side Aneurism 


2 years 
8 months 

7 weeks 


22d day 


59 
60 


Right side 
Right side 


Aneurism 

Anpnrism 


6 2d day 
15th day 
34th day 
22d day 
17th day 
22d day 
28th day 
30th day 


61 


Right side Diffuse femoral aneurism 
Left side Aneurism 

Left side Aneurism 

1 

Right side Aneurism 
Left side Aneurism 




62 
63 
64 
65 


3 months 
3 months 


66 

67 


6 months 
3 months 

19 months 


5 weeks 


68 
69 

70 

71 


Right side 
Right side 
Right side 
Left side 
Left side 
Left side 
Left side 
Left side 
Right side 
Left side 

Right side 
Right side 

Right side 
Left side 


Aneurism 
Hemorrhage from a 

sloughing carbuncle 
Aneurism 

Secondary hemorrhage 

from wound 
Aneurism 

Varicose inguinal aneu- 
rism 
Aneurism 

Aneurism 

Aneurism 

Hemorrhage following 
amputation 

Hemorrhage following 
amputation of thigh 

Varicose femoral aneu- 
rism 

Aneurism 

Aneurism 
Aneurism 

Hemorrhage from a 

wound 
Hemorrhage from a 

sloughing bubo 
Aneurism 

Secondary hemorrhage 

Aneurism 


30th day 
10th day 

24th day 


72 






73 


11 years 
4 months 




74 




75 


14th day 
29th day 
29th day 
17th day 


76 

77 


12 months 


7S 





79 


5 years 
11 weeks 


80 




81 
82 


19th day 


83 






84 






85 
86 

87 


2 months 


35th day 
17th day 
17th day 




• 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



239 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


Oct. 28, 1828 


Cured 
Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 
Died 

Cured 
Cured 

Cured 

Died 

Cured 

Died 

Died 

Cured 

Cured 

Cured 

Cured 

Died 

Died 

Cured 

Died 

Died 

Died 

Cured 

Cured 

Cured 






N. Amer. Med. and Surg. 

Journ., vol. vii., 1829. 
Med. Chirurg. Review, 

vol. xi., 1829. 

Edinburgh Med. and Surg. 

Journ., vol. xxxvi., 1831 . 

Amer. Journ Med. Sci., 


Nov. 7, 1829 
Jan. 3, 1831 


11th day 


Affection of the 

chest, probably 

diseased heart 


Nov. 30, 1830 






April 25, 1831 
July 19. 1831 
Oct. 6, 1831 






vol. xix., 1836. 
Amer. Journ. Med. Sci., 






vol. viii., 1831. 
London Med. nnd Phys. 
Journ., vol. xii., 1832. 






Oct. 7, 1831 






vol. vi., 1832. 
Amer. Journ. Med. Sci., 


Nov. 19 1831 






vol. x., 1832. 
London Med. nnd Phys. 

Journ., vol. xii. 1832. 
Lancet, vol. ii . 1832-3 


April 3, 1832 
Sept. 11, 1832 

May 21, 1833 
May 17, 1835 

June 21, 1835 






3d day 


Mortification of 
limb 


London Med. and Phys. 

Journ., vol xi., 1831. 
Lancet, vol. ii., 1832-3. 






Lancet, vol. i., 1838-9. 






Amer. Journ. Med. Sci., 


Jan. 7, 1836 


in 3 hours 




vol. xviii., 1836. 
Hosp. Report of Glasgow, 

from 1835 to Aug. 1836. 
Mems. de l'Acad. Roy. de 

Med., torn, vii., 1838. 
Amer Journ. Med. Sci., 

vol. xxii., 1838. 
Boston Med. and Surgical 

Journ., vol. xv., 1836. 
Amer. Journ. Med. Sci., 


June 15, '1836 




Nov. 5, 1836 
Dec. 5, 1836 
March 12, 1837 


3d day 
2d day 


Mortification of 
limb 

Delirium tre- 
mens 


June 23, 1837 






.vol. xxii , 1838. 
Edinburgh Med. and Surg. 

Journ., vol. i., 1838. 
Med. Chirurg. Transacts., 

vol. xx i., 1838. 
Lancet, vol. ii., 1838-9. 


Aug-. 22, 1837 






March 16, 1S38 






May 24, 1838 
July 17, 1838 
Auo\ 27, 1838 


5th day 
5th day 


Hemorrhage 
Prostration 


Gazette Medicale, No. xi , 

1841. 
Amer. Journ. Med. Sci., 

vol. iv., 1842. 
Gazette Medicale, 1839, p. 

586. 
On Aneurism, p. 121. 

Gazette Medicale, 1839, p. 

234. 
Boston Medical and Surg. 

Journ., No. xxvi., 1S39. 
N. Y. Journ of Med. and 


October, 1838 
1838 
1838 

June 30 1839 


4th day 
6th day 
4th day 


Diffuse inflam- 
mation 

Mortification of 
limb 

Mortification of 
limb 


1839 







Surg., vol. i., 1839. 
Journ. de Conn. Med. 


Oct. 18, 1839 






Chir., June, 1S39. 
Gazette Medicale, May, 
1839, No xix. 









240 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 


Surgeon. 


Sex. 

M. 
M. 
M. 
M. 


Age. 

57 
46 
36 
26 


Right or 
left side. 

Right side 

Left side 

Left side 


Disease. 


Duration 
of disease. 


Ligature 
separated. 


88 


Monod 
Thomson 
Baroni 
Houston 


Aneurism 

Hemorrhage following 
amputation 

Varicose inguinal aneu- 
rism 

Aneurism 


4 months 
1 year 




89 
90 
91 


18th day 
19th day 

22d day 


92 


Peace 


M. 


28 


Right side 


Aneurism 


4 months 


30th day 


93 


Venturoli 

Power 

Belling- 

ham 
Paul 

Boling 


M. 
M. 
F. 
M. 
F. 


50 
61 
32 
20 
20 


Left side 
Right side 
Right side 

Left side 


Aneurism 

Aneurism 

Aueurism 

Hemorrhage following 

amputation 
Aneurism 






94 


15 months 
3 months 

3 weeks 




95 
96 
97 


24th day 
34th day 
23d day 


98 


Brainard 


M. 


... 


Right side 


Aneurism 


12 weeks 


23d day 


99 


Lisfranc 
Taylor 


M 
M. 


24 


Right side 


Aneurism 
Aneurism 






100 


6 months 


16th day 

■ 


101 


B. Cooper 


M. 


42 


Right side 


Aneurism 


6 months 


22d day 


102 


Duncan 


M. 


30 




Aneurism 


9 months 


22d day 


103 

104 

105 

106 


Shepherd 

James 

Busk 
Liston 

Harrison 
Kidd 


M. 

M. 

M. 
M. 

M. 

F. 


48 

30 

32 
22 


Right side 

Left side 

Right side 
Right side 

Right side 
Right side 


Secondary hemorrhage 
after ligature of femoral 
Femoral and popliteal 

aneurisms 
Aneurism 
Aneurism foil, wound of 

a superficial branch of 

femoral 
Aneurism 

Aneurism 


8 months 
11 days 

3 or 4 

years 

5 years 


27th day 
15th (fciy - 
19th day 


107 




108 


19th day 


109 
110 


Gay 
Brodie 


M. 
M. 


48 
31 


Right side 


Aneurism 
Aneurism 


3 years 
3 weeks 


18th day 
25th day 


in 

112 


J. Cooper 
Fowler 

Malgaigne 
A. Cooper 
Rousset 
Crosse 

Crosse 


M. 
M. 

M. 
M. 
M. 
M. 

M. 


57 
30 

31 
38 
21 
31 

40 


Right side 
Left side 

Left side 

Right side 
Right side 

Left side 


Aneurism 

Inguinal and popliteal 

aneurisms 
Aneurism 
Aneurism 

Secondary hemorrhage 
Aneurism 

Aneurism 


6 months 
3 years 

15 months 


42d day 


113 
114 


16th day 


115 






116 
117 


upwards 
of 3 years 
18 months 


15th day 
16th day 


118 


Crosse 


M. 


... 


Right side 


Aneurism 


3or4 »' 


13th day 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



241 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


March 10, 1840 
Feb. 11, 1840 


Died 

Cured 

Died 

Cured 

Cured 

Died 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured after 
amputation, 
made neces- 
sary in con- 
sequence of 
gangrene of 

limb 
Cured 

Cured 

Cured 

Cured 
Died 

Died 

Cured 

Cured 
Cured 

Cured 
Died 

Cured 
Died 
Cured 
Cured 

Cured 

Cured 


7th day 


Sloughing of 
sac 


Archives Generales, 1840. 

Med. Chirurgical Review, 

July, 1841. 
Archives Generales, 1840. 

Dublin Journal of Med. 


1840 
June 23, 1840 


54th day 


Hemorrhage 


July 24, 1841 
1841 






vol. xxii., 1842. 
Philada. Med. Examiner 




Mortification of 

limb 
Hemorrhage 


vol. v., 1842. 
Annales de Chirurgie, 

torn, iii., 1842. 
Maryland Med. and Surg. 

Journ., vol. iii., 1841. 
Medical Exiiminer Oct 


July 19, 1842 
Aug. 26, 1842 
Aug. 31, 1842 
Auw. 1 1813 


5th day 






1842. 
Lond. and Edin. Monthly 

Journ., Feb. 1843. 
Amer. Journ Med Sci 






Feb. 24 1843 






vol. vii., 1844. 


May, 1836 
1835 






vol. vi., 1843. 






xli., 1836. 
Amer. Journ. Med. Sci., 

vol. xvii., ]836. 
Lancet, vol i., 1844. 


Feb. 20, 1844 




• 
1845 








Sept. 1, 1825 
Aug. 16, 1843 
Jan. 19, 1845 






March, 1845. 
Midland Med. and Surg. 

Reporter, vol. i., 1828-9. 
Provincial Med. and Surg. 

Trans., vol. xii. 
Lancet, vol i., 1845. 










May, 31, 1845 

June 17, 1845 
Oct. 28, 1845 


35 hours 
after 

8th day 


Peritonitis 
Tetanus 


Lancet, 1845. 

London Med. and Surgical 
Journ., Oct. 1845. 


Dec. 3, 1845 






1846. 


May 30, 1839 
Feb. 3, 1846 












i., 1846. 
Lancet vol. i 1846. 


Sept. 2, 1839 
Feb. 11, 1844 


30th day 


Mortification of 
limb 


Lancet, vol. ii., 1846. 

Journ. de Chirurgie, 1846. 
Roux's, Parallel, p. 236. 
Journ. de Chirurgie, 1846. 
Provincial Med. and Surg. 

Journ., Aug. 1846. 
Provincial Med. and Surg. 

Journ., Aug. 1846. 
Provincial Med. and Surg. 

Jurn., Aug. 1856. 


Aug. 19, 1816 
Oct. 9, 1843 


17th day 


Hemorrhage 


June 7, 1818 






Sept. 1825 
Sept. 7, 1842 















242 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Mortality. — Of the one hundred and eighteen cases included 
in the table, eighty-five recovered, and thirty-three died — three 
of the patients who recovered undergoing amputation in con- 
sequence of gangrene of the limbs. 

Sex. — Of one hundred and thirteen cases in which the sex 
is noted, one hundred and seven were males, and six females. 
Of the six females, five labored under aneurisms, and one had 
secondary hemorrhage. 

Right or left side. — Of seventy- nine cases in which the af- 
fected side is noticed, forty-four were on the right, and thirty- 
five on the left side. 

Age. — The age is given in ninety-nine of the cases, of which 
number there were — 



Under 


20 . 


. 4 


Between 20 and 30 . 


. 23 


it 


30 " 40 . 


. 32 


it 


40 " 50 . 


. . 25 


u 


50 " 60 . 


. 11 


u 


60 " 70 . 


. 3 


Above 


70 


. 1 



99 

Disease or injury. — Of the one hundred and eighteen cases 
of operations given in the table, ninety-seven were done for the 
cure of aneurisms, eighteen in consequence of woands or 
secondary hemorrhages, and three for the cure of varicose 
aneurisms. In four of the ninety-seven cases of aneurism, 
that disease existed simultaneously in both the ham and the 
front of the thigh, and in three of these the operation suc- 
ceeded in curing both tumors. 

Period the ligature separated. — This is noted in seventy-eight 
cases, in forty-four of which the ligature came away before 
the twentieth day; in twenty-four, between the twentieth and 
thirtieth days ; in seven, between the thirtieth and fortieth 
days ; and in three beyond the fortieth day. The earliest 
period at which the ligature came away was the tenth day, 
and the longest time to which it remained was the sixty- 
second day. 

Return of pulsation in the tumor after the application of the 
ligature. — This occurred in nine cases. In one of these (No. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 243 

18), evident pulsation was noticed in the sac on the fifth day, 
which gradually ceased at the end of ten or twelve days, the 
patient recovering. In the second case (No. 20), pulsation 
returned in the tumor more than two months after the opera- 
tion, and after a time ceased. In the third (No. 23), aneu- 
risms existed both in the popliteal and inguinal regions. Pul- 
sation in the ham entirely ceased upon the application of the 
ligature, but continued, though feebly, in the inguinal tumor; 
both aneurisms were ultimately cured. In the fourth (No. 
30), pulsation reappeared, and remained till the forty-fourth 
day, the patient recovering. In the fifth (No. 49), slight pul- 
sation was observed a few hours after the operation, and on 
the following day was so considerable, that compression was 
made on the artery, and kept up so as to arrest it ; the cure 
being complete. In the sixth (No. 90), which was a varicose 
inguinal aneurism, circulation through the tumor was observed 
to have returned on the third day, and the patient died after 
repeated hemorrhages, on the fifty-fourth day. In the seventh 
(No. 94), slight pulsation was noticed on the day following 
the operation, and the patient died on the fifth day of hemor- 
rhage. In the eighth (No. 104), both femoral and popliteal 
aneurisms existed. On the day after the operation, both tu- 
mors were solid ; no pulsation was perceived in the ham, but 
a slight tremulous motion was noticed in the groin. From 
this period, pulsation increased in the groin, and after a few 
days returned in the ham also, where, however, it soon en- 
tirely ceased. At the date of the report of the case (about 
six months after the ligature of the vessel), it continued in 
the groin, though very feebly. In the ninth (No. 110), the 
operation was done in the month of May, and the patient dis- 
charged cured in August, but was readmitted in the following 
November, with a return of pulsation in the tumor. Pressure 
was employed for two months, after which he was again looked 
upon as cured. In November, 1841, a recurrence of pulsation 
was again noticed. In January, 1842, all pulsation had ceased, 
but the tumor had increased. In January, 1843, it became 
stationary, and some time after began to diminish in size, and 
so continued to do till July of the same year, when he died of 



244 CONTRIBUTIONS TO PRACTICAL SURGERY. 

phthisis. On post-mortem examination, the tumor was found 
to be connected with the superficial femoral artery imme- 
diately below its origin, was of the size of a full-grown foetal 
head, and perfectly solid. 

Hemorrhage after the operation. — This is stated to have oc- 
curred in fourteen cases ; of these, seven died, and seven were 
cured. In Nos. 1, 79, 94, and 114, it took place on the fifth 
day, and in them all proved fatal. In the fourth and fifth 
cases (Nos. 25 and 99), hemorrhage once occurred in each, but 
the patients did well. In the sixth (No. 30), a considerable 
quantity of arterial blood escaped from the wound from the 
twenty-fourth to the thirtieth day, which was believed to 
come from the inferior end of the artery, and was successfully 
arrested by compression. In the seventh (No. 34), which 
was a case of hemorrhage from the upper and outer part of 
the thigh, the bleeding continued after the external iliac had 
been secured, and a ligature was placed on the femoral, which 
restrained it. The limb afterwards mortified, and was ampu- 
tated, the patient doing well. In the eighth case (No. 42), 
the hemorrhage occurred at several intervals between the 
twenty-fourth and forty-third days after the operation, when a 
second ligature was placed on the vessel higher up than the 
first, but without success. In the ninth (No. 48), repeated 
hemorrhages occurred after the nineteenth day, and the patient 
died. In the tenth (No. 77), the artery was ligatured on the 
22d of August, for hemorrhage following amputation ; on the 
28th, bleeding took place from the groin, which was restrained 
by pressure with a truss, and the patient cured. In the eleventh 
(No. 78), the vessel was also tied for hemorrhage after ampu- 
tation ; ligature of the femoral having been first tried ineffec- 
tually. On the day following the operation, there was a slight 
return, which was arrested by pressure. In the twelfth case 
(No. 90), which was one of varicose aneurism, it took place on 
the fortieth day after the application of the ligature from the 
inferior end of the wound. On the forty-third day there was 
another frightful return of it, when the aneurismal tumor was 
laid open with a view of tying all the bleeding vessels; the 
loss of blood when this was done, was such as to make the 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 245 

operator fear the man would die on the table ; he, however, 
lived eleven days. In the thirteenth (No. 96), the artery was 
tied to arrest hemorrhage from a stump, and more than six 
weeks after it, in consequence of a return of bleeding, it was 
again secured higher up than at first, and the patient cured. 
In the fourteenth (No. 114), it occurred on the seventeenth 
day, and proved fatal. 

Suppuration of the sac. — In ten cases, the tumor is stated to 
have suppurated after the operation, all of which did well. In 
one of these (No. 16), the integuments were in a state of mor- 
tification at the time of the operation, and on the twenty-third 
day after it, an incision was made into the tumor, and its con- 
tents evacuated. In another (No. 75), the tumor, which is 
stated to have been " of enormous size," suppurated and was 
punctured on the 25th of March. On the 31st and 2d of 
April, hemorrhages occurred from it, and a fruitless effort was 
made to take up the profunda. On the 12th, the bleeding was 
renewed, and the actual cautery was applied. On the 14th, 
" apprehensive of another hemorrhage," an effort was made 
to tie the internal circumflex without success, and the actual 
cautery was again resorted to. In a third (No. 95), where the 
ligature had been applied close to the bifurcation of the com- 
mon iliac, the tumor discharged itself through the wound on 
the twenty-first day, and in No. 113 the same occurrence had 
taken place on the twenty-ninth day. 

Gangrene of the limb. — This occurred in sixteen out of the 
one hundred and eighteen cases; three of which were cured 
after amputation, and twelve died. In one case (No. 31), the 
artery was tied on the 22d of January, mortification followed, 
which extended to the thigh, and on the 9th of February am- 
putation was done close to the trochanter. In a second (No. 
34), the ligature was applied August 27th, and the limb was 
amputated September 26th. In both of these cases the vessel 
was secured to restrain hemorrhage. In the third case (No. 
101), the operation was done for femoral aneurism on the 20th 
of February. The ligature separated on the twenty-second 
day, and about a week after this occurred, gangrene was ob- 
served in the toe, and gradually extended up to within a short 



246 CONTRIBUTIONS TO PRACTICAL SURGERY. 

distance of the knee, where the limb was removed. These 
amputations were all successful. In one instance (No. 61), 
slight sloughing of the sole of the foot occurred from a bottle 
of hot water applied to the part. 

Cause of death. — Of the one hundred and eighteen cases, 
thirty-three died. Of these, six died from hemorrhage ; three, 
from sloughing of the sae; thirteen, from mortification of the 
limb ; one, from the bursting of an aneurism of the aorta at its 
bifurcation, ten weeks and six days after the operation ; two, 
on the third and fifth days from prostration ; two, of perito- 
nitis ; two, of tetanus ; one, on the eleventh day of some affec- 
tion of the chest — probably diseased heart ; one, on the second 
day, of delirium tremens ; one, of diffuse inflammation, and in 
one, the cause is not noted. 

Difficulties of and accidents during the operation. — In two in- 
stances (Nos. 20 and 51), the peritoneum was wounded in the 
operation. Both patients recovered. In one (No. 74), the 
sac was accidentally wounded after the ligature was applied. 
In one (No. 91), a vein — the circumflex ilii — was a source of 
much embarrassment to the operator, who gives with his case 
a plate representing it. 

Mistakes in diagnosis. — In four of the cases given in the 
table (Nos. 22, 40, 67, and 88), the tumors had been mistaken 
for abscesses and opened previous to the operation. Of these 
none recovered. In No. 106, the aneurism which followed a 
gunshot wound was supposed to arise from a wound of the 
femoral. Upon examination it was found that the ball did 
not pierce the fascia lata, but had passed altogether in the 
subcutaneous fat, and that the only vessel wounded was a su- 
perficial branch of the femoral artery, which was divided close 
under Poupart's ligament and nearly an inch from the main 
trunk. 

Mr. Fergusson 1 mentions that he has seen " a most expe- 
rienced and judicious surgeon cut through the parietes of the 
abdomen with the intention of tying the external iliac artery 
for a supposed aneurism where none existed." This case is, I 

1 Elements of Surgery, p. 135. Arner. edit., 1845. 



MORTALITY FOLLOWING LIGATURE OP ARTERIES. 247 

presume, that which has been recorded by Mr. Syme in one of 
his Surgical Eeports in the Edinburgh Journal, and is well 
calculated to show the difficulty of diagnosis which is some- 
times met with. The tumor, which was stated to have followed 
a misstep made some eight months before his presenting him- 
self for examination, was situated in the right iliac region of 
a man aged 54. It was tense, pulsated obscurely throughout 
its whole extent, and offered a distinct bellows sound upon 
the application of the stethoscope. Believing that an aneu- 
rism existed, Mr. S. made an incision into the abdomen, six 
inches in length, with the intention of securing the external or 
common iliac, but when exposed, the tumor was found to be 
composed of a solid cerebriform mass, and was taken away en- 
tire. Seven days after it the patient died, and on dissection, 
a chain of tumors similar in nature was found surrounding the 
great vessels on both sides. 

Internal Iliac Artery. — I am aware of only seven in- 
stances in which this vessel has been ligatured. These were 
by Stevens, Atkinson, Thomas, White, Arendt, Mott, and J. 
K. Eodgers. Of these, three died, and four were cured. In 
all of them the operation was done for the cure of aneurisms, 
and in one of them (Mott), although the peritoneum was 
opened in the efforts to separate it from the parts beneath, yet 
the patient did well. 

Common Iliac Artery. — Fifteen cases are recorded in 
which the operation of tying the primitive iliac has been per- 
formed. The first case in which it was done was that of a 
gunshot wound, in 1812, by Dr. W. Gibson, of this city. The 
patient died from peritoneal inflammation and secondary 
hemorrhage on the thirteenth day. The second case was that 
of Dr. Mott, for aneurism, in 1827, and was fully successful. 
The third was in 1828, by Mr. Crampton, also for aneurism, 
and was unsuccessful, the patient dying on the fourth day 
from hemorrhage. The fourth case was that of a boy, aged 
eight, in whom the common iliac was tied by Mr. Liston, in 
1829, in consequence of secondary hemorrhage after amputa- 
tion, and was unsuccessful. The fifth was the case of a lady 
operated on in 1833, by Mr. Guthrie, for a tumor on the right 



248 CONTRIBUTIONS TO PRACTICAL SURGERY. 

nates as large as an adult head, which presented so decidedly 
the characters of aneurism that it was believed to be so by 
Mr. Gr., as well as by Sir Astley Cooper and others, who ex- 
amined it. Pulsation was manifest in every part of it, and 
" on putting the ear to it, the whizzing sound attendant on 
the flowing of blood into an aneurism could be very decidedly 
heard." Diminution of the tumor to the extent of one-half 
followed, and recovery from the operation was complete. 
Five months after it the tumor again enlarged, and she gradu- 
ally sunk. On post-mortem examination, eight months after 
the operation, the arteries were found to be perfectly healthy 
and the tumor to consist of cerebriform matter. The sixth 
was by Mr. Salomon, of St. Petersburg, in 1837. The cure 
was deemed perfect, the tumor almost disappeared, and the 
free use of the limb was restored. Ten months after, the pa- 
tient is stated to have taken cold, and had an abscess to form 
upon the affected side, which was opened just below Poupart's 
ligament. He died shortly after, worn out by the suppura- 
tion. The seventh case was that of Mr. Syme, in 1838, for 
.aneurism, and was unsuccessful, the patient dying on the 
fourth day. The eighth was by Deguise of Paris, in 1840, 
and proved successful, despite three serious accidents which 
happened during its performance, viz., the wounding of the 
sac, the giving way of the vessel under a first ligature, and 
the wounding of the femoral vein in the taking up of the ar- 
tery of that name which was done at the same time to prevent 
secondary hemorrhage. The ninth was in a case of aneurism, 
aged twenty, which occurred to Dr. Post, of New York, in 
1840. The symptoms here were deceptive, and it being judged 
that deep fluctuation was present, an explorative incision was 
made into it. On the following night there was a sudden gush 
of arterial blood, which was arrested by compression, and the 
day after, a ligature was applied to the common iliac by cut- 
ting through the peritoneum, the tumor extending so high up 
that it was thought impracticable to expose the vessel without 
it. The patient sunk twenty-four hours after the operation, 
from exhaustion and loss of blood. The tenth case was that 
of a female child, aged two months, in whom the artery was 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 249 

secured by the late Dr. Bushe, on account of a large aneurism 
by anastomosis of the left labium. The child lived five weeks. 
In the eleventh case the ligature was applied by Dr. Pirogoff 
on account of hemorrhage after the removal of a ligature from 
the external iliac, which had been applied for the cure of 
aneurism. In exposing the vessel, the peritoneum, which 
was adherent, was torn through. The wound became gangre- 
nous, and on the eleventh day, fecal matter was discharged 
through it. On the fourteenth day hemorrhage occurred, and 
the patient died twenty-four hours after it. The twelfth case 
was that of my colleague at the Pennsylvania Hospital, Dr. 
Peace. The operation was done in August, 1842. The tu- 
mor, which extended from three inches below to the same 
distance above Poupart's ligament, had become, five months 
after the operation, reduced to the size of a filbert, and was 
perfectly hard. On the 13th of November, 1843, he presented 
himself for readmission at the hospital, and stated that after 
being last seen he had returned to his employment — that of 
loading boats with stone — and had continued perfectly well 
and able to work up to within two weeks, when his attention 
was directed to a reappearance of his tumor. Upon exami- 
nation it was found to be of the size of a small orange, was 
soft, entirely free from pulsation, presenting evident marks of 
fluctuation, and the skin covering it discolored. A few days 
afterwards an opening took place in it and was followed by 
considerable hemorrhage, which was arrested by compres- 
sion. Several recurrences of this followed, and he died on 
the 24th. The thirteenth case was an aneurism operated on 
by Mr. R. Hey in 1843, and was successful. The fourteenth 
is the interesting case of supposed aneurism which has been 
published by Mr. Stanly. On applying the ear over the ab- 
dominal parietes, a bellows sound in the tumor was plainly 
recognized. Compression applied to the femoral artery below 
the tumor produced enlargement of it, but when made upon 
the aorta, all pulsation was arrested ; after the application of 
the ligature to the common iliac, pulsation ceased. Death 
occurred on the third day from peritonitis. Upon dissection 
17 



250 CONTRIBUTIONS TO PRACTICAL SURGERY. 

the arteries were found to have no connection with the tumor, 
which was composed of medullary matter. Tumors of a simi- 
lar character were found in the heart and lungs, and one of 
the size of an orange occupied the middle and inner side of 
the arm, which during life was observed to be free from pul- 
sation or pain, and was said to have existed for several years. 
The fifteenth and sixteenth cases are those which have been 
published by Dr. Garviso of Monte Yideo. The first, which 
occurred in 1837, was an aneurism of the external iliac which 
extended from the pubis to the umbilicus, and was of the size 
of an adult's head. An eschar which had formed on the tu- 
mor had commenced to separate and gave rise to abundant 
hemorrhage immediately previous to the performance of the 
operation. From the size and situation of the tumor the 
cavity of the peritoneum was necessarily opened. Death fol- 
lowed in four hours. The second of his cases — also an aneu- 
rism — was in 1843. The incision was made with a view of 
securing the external iliac, but the disease was found to ex- 
tend so high up that the common trunk was tied. The liga- 
ture separated on the thirty-sixth day, and the patient reco- 
vered. Total, sixteen cases, of which eight may be said to 
have been successful, and eight died. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 251 



MOETALITY FOLLOWING THE LIGATURE OF THE CAROTID 
ARTERIES AND ARTERIA INNOMINATA. 

Close examination of the cases recorded in the present 
tables shows that the operation of deligating the carotid has 
been too generally looked upon as one of but comparatively 
little danger ; an analysis of them proves that serious symp- 
toms frequently follow the mere cutting off of the supply of 
blood to the brain through this vessel, at the same time that 
it strikingly exhibits the frequency and severity of the other 
accidents which follow it, and throws some light upon the 
rate of mortality attendant upon operations on the great ves- 
sels of the neck. 



252 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



III. Mortality following the Operation of Tying 

Series I. — 






• > 



No, 

1 

2 

3 

4 

5 
6 

7 

8 

9 
10 

11 

12 

13 
14 
15 

16 

17 
18 

19 

20 

21 

22 

23 

24 

25 

26 

27 
28 
29 

30 

31 

32 

33 

34 

35 
36 

37 

38 



Surgeon. 



Cooper 

Cooper 

CHne 
Macaulay 

Post 

Dupont 



Coates 

Porter 
Vincent 

Holseher 

Perry 

Sykes 

Key 

Warren 

Lisfranc 

Scarpa 
Vincent 

Maurin 

Sisco 

Lyford 

Chiari 

Green 

Dehane 

Marchal 

Randolph 

Robertson 
Porter 
B. Cooper 

Kerr 

Liston 

Johnson 

Syme 

Fairfax 

Eccles 
Duncan 

O'Reilly 

White 



Sex. 



F. 

M. 

M. 
M. 

M. 

M. 

F. 

M. 

F. 

M. 

M. 

M. 

F. 
M. 
M. 

F. 

F. 
M. 

M. 

M. 

M. 
M. 
M. 

F. 

M. 

M. 

M. 
M. 
M. 

F. 

M. 

M. 

F. 

F. 

M. 
F. 

M. 

M. 



Age. 



Right or 
left side. 



44 
50 

36 

35 

27 

41 

40 
52 

23 

39 

18 
40 
42 

29 
48 

40 

17 

36 

28 

65 

10 

25 

25 

52 
38 
34 

67 

9 

29 

60 

46 
30 

44 

34 



Right side 
Left side 



Left side 
Right side 
Left side 



Disease. 



Left side 



Aneurism 

Aneurism 

Aneurism 

Aneurism from wound 

Aneurism 

Aneurism 

Aneurism from wound 

Aneurism 



Right side Aneurism 
Right side Aneurism 

j 

Right side Aneurism 

Right side Aneurism 

I 
Right side Aneurism 

Aneurism 

Left side Aneurism 

Right side Supposed aneurism 

Right side Aneurism 
Right side Aneurism 

Left side Aneurism 



Left side 



Left side 

Right side 

Right side 

Left side 

Right side 

Right side 
Left side 
Right side 

Right side 

Right side 

Right side 



Left side 



Aneurism from wound 

Aneurism 

Aneurism from wound 

Aneurism 

Aneurism from wound 

Aneurism from wound 

Varicose aneurism 

Aneurism 
Aneurism 
Aneurism 

Supposed aneurism 

False aneurism 

Aneurism 

Aneurism of internal 

carotid 
Aneurism 



Right side Supposed aneurism 
Right side Aneurism 

Right side Supposed aneurism 

Right side Aneurism 



Duration 
of disease. 

5 months 

7 months 



5 days 

10 months 

6 months 
6 weeks 

6 months 

15 years 
3 weeks 



2 years 

3 years 

5 months 

4 years 



8 months 

1 month 

2 or 3 
week3 

3 weeks 



Ligature 
separated. 



11th day 

22d and 
23d days 



16th and 
18th days 



14th day 



19th day 
22d day 

15th day 

13th day 

10th day 
7th day 



5 months 



2 months 



21st day 

14lh day 
27th day 



24th day 
11th day 



2 months 1 7th day 
5 weeks 15th day 
12 months 33d day 

26th day 



2 months 
5 weeks 
5 months 



22d day 



2 years 

3 months 10th day 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



253 



the Carotid Arteries and Arteria Innominata. 

Aneurisms. 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


November 1, 1805 
June 22, 1808 


Died 

Cured 

Died 
Cured 

Cured 

Cured 

Cured 

Died 

Cured 
Died 

Cured 

Cured 

Cured 

Died 

Cured 

Died 

Cured 
Died 

Cured 

Cured 

Cured 

Died 

Recovered 

Cured 

Died 

Died 

Cured 

Died 

Cured 

Recovered 

Died 

Cured 

Died 

Died 

Recovered 
Died 

Died 

Cured 


21st day 


Inflammation 
of sac 


Med. Chirurg. Transacts., 

vol. i. 
Med. Chirurg. Transacts., 

vol. i. 
Lond. Med. Review, vol. ii. 
Edin. Med. and Surg. 

Journ., vol. x. 
Amer. Med. and Phil. Re- 


Dec. 16, 1808 
Dec. 16, 1812 


4th day 


Hemorrhage 


January 9, 1813 
1814 










gister, vol. iv. 
Breschet's Trans, of Hodg- 
son, torn. ii. 
Hodgson on the Arteries, 

1815. 
Med. Chirurg. Transacts., 

vol. xi. 
Dub. Hosp. Reports, vol. v. 
Med. Chirurg. Transacts., 

vol. X. 
Lond. Med. Repository, 

vol. xvi. 
Glasgow Med. Journ., vol. 

iv. 
Phila. Journ., vol. vi. 








January 3, 1817 
August 21, 1829 


70th day 


Hemorrhage 


Dec. 19, 1818 
Sept. 27, 1819 
Nov. 14, 1820 


33d day 


Inflammation 
of sac 






June 20, 1821 






January 24, 1824 
October 26, 1827 


10th day 




Lancet, vol. i., 1823-4. 




Boston Med. & Surg. 

Journ., vol. i. 
Am. Journ. of Med. Sci , 

vol. ii. 
Lancet, vol. i., 1828-9. 


1827 

May 23, 1828 
July 18, 1829 

Nov. 20, 1829 


8th day 


Hemorrhage 


7th day 


Inflammation 
of brain 


Med. Chirurg. Transacts., 

xxix. 
Lond. Med. & Phys. 

Journ., vol. viii., N. S 
Archives Generales, torn. 








October 30, 1818 






vol. xxiii. 
Med. Chirurg. Transacts., 

vol. xi. 
Med. Operat. of Velpeau, 

torn. 2, 1839. 
Dublin Journ. and South's 


July 18, 1829 
April 15, 1831 
January 20, 1832 
June 19, 1835 


9th day 








Trans, of Chelius. 
Am. Journ. of Med. Sci., 


6th day 
day after 




vol. X. 
Journal Hebdomadaire, 


1836 
March 21, 1837 


Congestion of 
brain 


torn. iv. 
At Pennsylvania Hospital. 

Dublin Journal, vol. xii. 


Sept. 22, 1838 
April 7, 1840 

April 30, 1840 

October 21, 1841 

January 22, 1842 

April, 1842 

July 18, 1842 

Sept. 23, 1843 
Dec. 25, 1843 

July 20, 1844 

August 28, 1845 


6wk'safter 


Hemorrhage 


Dublin Journal, vol. xvii. 

Guy's Hospital Reports, 
No. 13, 1841. 

Edin. Med. & Surg. Journ., 
vol. lxi. 

On a variety of False Aneu- 
rism, 1842. 

Lond. Med. Gazette, vol. 






15th day 


Hemorrhage 


in 30 hours 
5th day 




ii., 1841-2. 
London and Edin. Monthly 

Journ., 1842. 
Phila. Medical Examiner, 

vol. vi. 
Lancet, 1844. 


Exhaustion 


17th day 
9th day 


Spasm of glot- 
tis 
Apoplexy 


Edin. Med. & Surg. Journ., 

vol. Ixii. 
Dublin Medical Press, Oct. 

1844 
Lancet, February, 1846. 







254 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Series II. — 



No. 


Surgeon. 


Sex. 

M. 
M. 
M. 
M. 
M. 

M. 

M. 

M. 

M. 

M. 
M. 

M. 

P. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 


Age. 


Right or 
left side. 


Disease. 


Duration 
of disease. 


Ligature 
separated. 


1 


Fleming 

Abernethy 

Twitchell 

Dupuytren 

Marjolin 

Giroux 

Collier 

Travers 

Brodie 

Brown 

Cusack 
Boileau 

De Cruz 

Miller 

Travers 

Mayo 

Luke 

Langen- 

beck 
Horner 

Syme 

Tyertnan 

Mayo 

Ellis 

Bedor 

Duncan 

Sedillot 

Spence 

Peace 

Vincent 

Clark 


20 
42 
20 

29 

27 

35 

36 
36 

44 

35 
23 

45 
29 
34 
9 
35 
30 
28 
20 
60 
19 
38 
22 
28 
29 


Left side 
Right side 
Right side 

Left side 
Right side 
Left side 
Right side 

Right side 
Left side 

Right side 
Right side 
Left side 

Right side 
Left side 
Right side 
Right side 

Left side 
Left side 
Right side 
Left side 
Right side 
Right side 
Left side 


Hemorrhage after 
wounded throat 
Wounded throat 

Hemorrhage after 
wounded neck 

Hemorrhage after gun- 
shot wound 

Hemorrhage after gun- 
shot wound 

Hemorrhage after gun- 
shot wound 

Hemorrhage after wound 
at angle of jaw 

Hemorrhage from fun- 
gous tumor of cheek 

Hemorrhage following 
extraction of a tooth 

Hemorrhage after 
wounded throat 

Wounded throat 

Wounded throat 

Wounded throat 

Hemorrhage after 
wounded throat 
Wounded throat 

Hemorrhage from ulcer 

in throat 
Hemorrhage from ulcer 

in throat 
Hemorrhage after tying 

thyroids for goitre 
Wounded throat 

Hemorrhage from ear 

and fauces 
Wounded throat 

Hemorrhage after 
wounded throat 

Hemorrhage after 
wounded throat 

Hemorrhage after 
wounded throat 

Hemorrhage from ulcer 
in throat 

Hemorrhage following 
wound of ext. carotid 

Hemorrhage from ulcer- 
ation of face 

Hemorrhage from ulcer- 
ation behind jaw 

Hemorrhage after 
wounded tongue 

Wound of external ca- 
rotid 


10 days 
22 days 

6 days 

5 th day 

7 days 

27 days 

8 days 
8 days 

13 days 

8 days 




? 




3 

4 


13th day 


a 




6 




7 
8 


13th day 


9 




10 

11 
1?, 


12th day 
21st day 


13 




14- 




15 
16 
17 

18 


13th day 
15th day 
22d day 


19 
20 


24th day 


21 


11th day 


23 
24 
R6 


9 th day 
14th day 


26 




27 




28 
29 


12th day 


30 


16th day 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 

Wounds, etc. 



255 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


October 17, 1803 


Cured 

Died 

Cured 

Died 

Died 

Died 

Cured 

Died 

Died 

Cured 

Died 
Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Died 

Died 

Died 

Died 

Died 

Cured 


30 hours 
after 

6th day 
2d day 
9 th day 

16 th day 
2d day 

60th day 

58th day 

24 hours 
after 

13th day 

14th day 
10th day 
61st day 
31st day 
6th day 




Med. Chir. Review, Jan. 




Inflammation of 
brain 


1827. 
Surgical Works, vol. ii. 

New Eng. Quart. Journ. of 
Med. and Surg. ,Oct.l842. 

Breschet's Trans, of Hodg- 
son, torn. ii. 

Breschet's Trans, of Hodg- 
son, torn. ii. 

Breschet's Trans, of Hodg- 
son, torn. ii. 

Med. Chir. Transacts., vol. 


October 18, 1807 


February 24, 1814 
1814 
1814 

June 22, 1815 




Hemorrhage 

Effusion of blood 
at base of brain 


April 13, 1816 
July 5, 1816 
June 14, 1817 




vii. 
Lond. Med. and Phys. 

Journ., April 1827. 
Med. Chir. Transacts., vol. 




viii. 
Dublin Hospital Reports, 

vol. i. 
Dub. Hosp. Rep., vol.iii. 
North American Med. & 

Surg. Journ., vol. i. 
Boston Med. & Surg. 

Journ., vol. ii 
Western Journal, vol. i. 


August 16 
July 22, 1822 

February 27, 1825 

October 9, 1825 


Hemorrhage 




June 27, 1826 
October 19, 1828 


Hemorrhage 


Lond. Med. and Phys. 

Journ., vol. i., N. S. 
North American Med. & 


October 4 1829 




Surg. Journ., April, 1830. 
London Medical Gazette. 


1829 
June 18, 1832 


Inflammation of 
brain 


Archives Generales, torn. 

xix. 
Am. Journ. of Med. Sci., 


Sept. 18, 1832 
August 14, 1834 




vol. X. 
Edin. Med. and Surg. 

Journ., vol. xxxviii. 
Med. Chir. Review, vol. 




1834 
January 26, 1835 
April 24, 1835 
March 29, 1836 
April 1842 
May 29, 1842 
November 8, 1844 
April 16, 1845 
October 14, 1846 


Inflammation of 
brain 


xxiv., N. S. 
Medical Quarterly Review, 

vol. i. 
Lancet, vol ii., 1834—5. 




La Presse Medicale, No. x. 


Bronchitis 


Edin. Med. &Surg. Journ., 

vol. lxii. 
Gazette Medicale, No. 


Exhaustion 

Hemorrhage 

Hemorrhage 


xxxvi., 1842. 
London & Edin. Monthly 

Journal, vol. ii. 
At Pennsylvania Hospital. 

Medico-Chirurg. Trans., 

vol. xxix. 
Lond. Med. Gazette, Feb. 






1847. 



256 



CONTRIBUTIONS TO PRACTICAL SURGERY. 

Series III Extirpation 



No. 


Surgeon. 


Sex. 
F. 


Age. 


Right or 
left side. 


Disease. 


Duration 
of disease. 


Ligature 
separated. 


1 


Cogswell 


37 


Left side 


Parotid tumor 


6 months 


14th day 


2 


Goodlad 


F. 


... 


Left side 


Parotid tumor 




11th day 


3 


Mott 


M. 


49 


Right side 


Fungous tumor in neck 




14th day 


4 


Mott 


F. 


17 


Right side 


Osteo-sarcoma of jaw 


2 years 


15th day 


5 


Mott 


F. 


22 


Left side 


Osteo-sarcoma of jaw 


1 year 


14th day 


6 


Mott 


M 


18 


Right side Osteo-sarcoma of jaw 
Right side Ossifio tumor of iaw 


6 years 
18 months 




7 


Awl 
Fouilloy 

Stedman 


F. 
F 


12 
53 




8 


Left side 




15th day 
26th day 


9 


M. 


58 


Right side 


Parotid tumor 


12 years 


10 


Seott 
Ewing 
Mott 
Gibson 


M. 
M 


45 
fifl 


Right side Tumor of faoe 


4 months 
30 years 

5 years 
5 years 




11 


Right side 
Left side 


Tumor in neck 




12 


F. 
M. 


19 
17 


Tuberculated sarcoma 

of neck 
Medullary tumor in neck 




13 


36th day 


14 


Luzenburg 
Warren 


M. 


62 


Left side 


Parotid tumor 


20 years 
30 years 




15 


M. 


52 


Right side 


Scirrhous tumor in neck 




16 


Roux 
Brett 


F. 

F. 


30 
17 


Right side 


Parotid tumor 
Parotid tumor 


2 years 
5 years 




17 




18 


C. B. Gib- 
son 


F. 


35 


Right side 


Osteo-sarcoma of jaw 


6 years 


2 2d day 



Series IV. — Cerebral 



No. 


Surgeon. 


Sex. 


Age. 


Right or 
left side. 


Disease. 


1 

2 


Liston 
Becton 


F. 
M. 


24 
22 


Left side 
Left side 


"Beating pain in left cheek and jaw, stretching 
to the throat, and, indeed, involving whole 
head" 

Epilepsy 


3 


Preston 


M. 


50 


Right side 


Hemiplegia of left side 


4 


Preston 


M. 


25 




Epilepsy 


5 


Preston 


M. 


51 


Right side 


Epilepsy and hemiplegia 


6 


Preston 


M. 


24 


Right side 


Headache and partial paralysis 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



257 



of Tumors. 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of 
death. 


Work. 


Nov. 4, 1803 

Sept. 5, 1815 
Nov. 14, 1818 


Died 

Cured 

Died 

Cured 

Cured 

Died 

Cured 
Cured 

Cured 

Died 

Died 

Cured 

Cured 

Cured 

Recovering 
on 8th day 
Died 
Cured 

Cured 


20th day 


Hemorrhage 


New England Journ. of 

Med. and Surg., vol. 

xiii., 1824. 
Medico-Chirurg. Trans., 

vol. vii. 
Med. & Surg. Register, 

Part 2d. 
New York Med. and Phys. 

Journ., vol. i. 
New York Med. and Phys. 

Journ., vol. ii. 
New York Med. and Phys. 

Journ., vol. ii. 
Western Journal, vol. i. 


3 mos. & 19 
days after 




Nov. 18, 1821 




March 30 1823 






May 15, 1823 

1827 


4th day 


Inflammation 
of chest 


1828 






Sept. 7, 1830 
Feb. 4, 1832 
Feb. 11, 1832 
February 1832 
Nov 20 1832 






xviii. 
Medico-Chirurg. Review, 

vol. xvi., N. S. 
London Medical Gazette, 

vol. ix., 1832. 
Edin. Med. and Surg. 

Journal, vol. xxxviii. 
Am. Journ. of Med. Sci., 


42 hours 

after 
4th day 


Convulsions 

" Gradually 
sunk" 






vol. xii. 
Am. Journ. of Med. Sci., 


1834 






vol. xiii. 
Annales de Chirurgie, 

torn. vi. 
On Tumors, p. 183. 

Gaz des Hopitaux, 1837. 
India Journ. of Med. & 


March 7 1837 






June 19 1837 


14th day 








June 12 1S44 






Phys. Sci., August 1839. 
Am Journ. of Med. Sci., 








vol. viii., N. S. 



XX.S £ XjKji.±\Jiya. 










Duration of 
disease. 


Ligature 
separated. 


Date of 
operation. 


Result. 


Work. 




22d day 


June 22, 1817 

Mar. 21,1827 
Nov. 22, 1830 
Feb. 4, 1831 
Aug. 23, 1831 
Sept. 2, 1831 


Recovered 

Recovered 
Recovered 
Recovered 
Recovered 
Recovered 


Edin. Med. and Surg. 


9 years 

1 month 

5 years 

Fits 6 years, pal- 
sied 20 days 


Journ., vol. xvi. 
North American Med. & 


18th day 
29th day 


Surg. Journ., vol. iv. 
Transacts Med. Phys. Soc. 

of Calcutta, vols. v. & vi. 
Transacts. Med. Phys. Soc. 

of Calcutta, vols. v. & vi. 
Transacts. Med. Phys. Soc 

of Calcutta, vol. vi. 
Transacts. Med. Phys. Soc. 

of Calcutta, vol. vi. 







258 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Series Y. — Erectile Tumors, Tumors op 



c 


Surgeon. 


Sex. 


Age. 


Right or 
left side 


Disease. 


Duration 
of disease. 

4 years & 

5 months 
9 months 

6 weeks 


Ligature 
separated. 


1 

2 

3 


Travers 

Dalrymple 
Wardrop 


F. 
F. 


34 

44 

six 

w'ks 

20 

26 
35 
18 


Left side. 

Left side 
Left side 


Erectile tumor in orbit 

Erectile tumor in orbit 
Erectile tumor in cheek 


21st and 
22d days 
27th day 


4 

5 

6 
7 


Dupuytren 

Jameson 

Arendt 

Pattison 


M. 

M. 
M. 
M. 


Eight side 

Right side 
Left side 


Erectile tumor of ear and 

temple 
Fungus of the antrum 
Erectile tumor of face 
Erectile tumor of face 


13 months 
S years 


12tb day 
17th day 


8 


Davidge 


M. 


.. 


Left side 


Fungus of the antrum 







9 
10 


Finley 
Barovero 


M. 
M. 


•• 


Right side 
Right side 


Fungus of the antrum 
Tumor behind the jaw 


some 
months 


19th day 


11 
12 
13 

14 


McClellan 
McClellan 
McClellan 

Wardrop 


F. 

F. 
M. 

F. 


5 

9 
16 

five 


Left side 
Left side 
Right side 

Left side 


Erectile tumor in orbit 
Erectile tumor of cheek 
Vascular fungus from 

dura mater 
Erectile tumor of face 


4| years 


14th day 

14th day 

about 

2 weeks 

11th day 


15 


Frick 


•- 






Cancer of parotid 


.... 




16 


Mayo 


M. 


26 


Right side 


Fleshy tumor of neck 


.... 


17th day 


17 

18 
19 


Magendie 
Wardrop 
Maclachlan 


F. 
M. 
M. 


25 

22 
30 


Left side 
Left side 
Left side 


Tumor of maxillary 

sinus 
Erectile tumor of face and 

head 
Pulsating tumor on scalp 


12 years 


11th day 
25th day 


20 


Williaume 


M. 


24 


Left side 


Fungous tumor on tem- 
ple 

Erectile tumor in orbit 

Erectile tumor on inside 
of cheek 

Erectile tumor of face 





21st day 


21 
22 

23 


Warren 
Bushe 

D. L. Eogers 


F. 

M. 


18 
19 

eight 


Right side 
Left side 

Right side 


from birth 
from birth 


29th day 


21 


Mayo 


M. 


five 


Left side 


Erectile tumor of face 





8th day 


25 
26 
27 


Mighels 
Velpeau 
Chelius 


F. 
M. 
M. 


23 
16 
19 


Left side 
Left side 
Right side 


Erectile tumor of face and 

occiput 
Erectile tumor of tempo- 
ral fossa 
Aneurismal varix of tem- 
ple 
Erectile tumor in orbit 
Erectile tumor in orbit 
Erectile tumor in orbit 


2 years 
1 year 


30th day 
21st day 


28 
29 
30 


Busk 

Scott 
Miller 


M. 
M. 
F. 


20 
42 


Right side 
Right side 
Right side 


6 months 
1 month 
IS months 


13th day 


31 

32 


Pirogoff 

Zeiss 




nine 
mos. 
fifteen 


Left side 
Left side 


Erectile tumor on occi- 
put 
Erectile tumor of face 


9 months 
15 months 


removed 

on 8th day 

8th day 


33 
34 


Jobert 
Auchinloss 


M. 
F. 


23 


Right side 
Left side 


Erectile tumor in orbit 

Erectile tumor on tem- 
ple 
Erectile tumor in orbit 
Erectile tumor in orbit 


3 years 
from birth 


1 month 

after 
19th day 


35 

36 


Velpeau 
Caldwell 


M. 
F. 


60 


Right side 
Right side 


1 year 


39th day 


37 


Dudley 


M. 




Right side 


Erectile tumor in orbit 


several 




38 


Blackman 


M. 


30 


Right side 


Fungous tumor of neck 


years 
2 years 




39 

40 


Liston 
A. C. Post 


M. 
M. 


20 
27 


Right side 


Arterial varix of scalp 
Erectile tumor of cheek 


spot from 
birth, but 




41 

42 


Bos 
Petrequin 


F. 
M. 


17 
22 


Right side 
Left side 


Tumor of the diploe 
Erectile tumor in orbit 


increasing 
for 3 years 
20 months 
5 months 





MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



259 



Diploe, Jaw, Maxillary Sinus, and Neck. 



Date of 
operation 



May 23, 1S09 
April 7, 1*813 



April 8, 1818 

Nov. 11, 1820 
Nov. 8, 1821 
1821 

April, 1823 

July 27, 1824 

May 19, 1825 

June 10, 1825 
1S25 
1S25 

March, 1826 

1S26 

Jan. 20, 1S27 

March 4, 1827 

1827 

July 10, 1825 

June 26, 1829 

Jan. 2, 1830 
Jan. 15, 1830 

Dec. 12, 1832 



Mar. 12, 1835 

1835 

Jan. 18, 1836 

Feb. 2, 1S36 
Nov. 10, 1S36 
1S36 

Jan. 26, 1837 

Aug. 30 

Aug. 7,1839 

July 7, 1839 

1839 
Sept. 16, 1840 

Jan. 1841 

June 21, 1843 



April 12, 1845 



June 5, 1845 



Result. 



Cured 

Cured 
Died 

Recov. 

Cured 
Cured 
Cured 

Died 

Recov. 

Died 

Cured 
Cured 
Cured 

Cured 

Died 

Recov. 

Recov. 

Cured 

Died 

Recov. 

Cured 
Cured 

Cured 

Recov. 

Cured 

Died 

Recov. 

Cured 
Cured 
Died 

Died 

Died 

Cured 

Cured 

Recov. 
Cured 

Cured 

Died 

Died 
Died 



Died 
Recov. 



Period 
of death. 



14th day 



6 weeks 



69th day 



4th day 



16th day 



8 days 

after 
117 days 

after 
114 days 

after 



Sth day 
10 days after 



Cause of death. 



Irritation of ulcer 



Lock-jaw 



Inflammation of brain 



Long-continued con- 
stitutional disturbance 
occasioned by disease. 



Inflammation of chest 



Repeated hemor- 
rhages 



Apoplexy 

Hemorrhage 

Convulsions 



Long-continued con- 
stitutional disturbance 

Hemorrhage 

Phlebitis of internal 
jugular 



Diarrhoea & hemorrh'ges 



Work. 



Med. Chirurg. Trans., vol. ii. 

Med. Chirurg. Trans., vol. vi. 
Med. Chirurg. Trans., vol. ix. 

Lemons Orales, torn. iv. 

Philad. Med. Recorder, vol. iv. 

Lancet, 1S2S-9. 

Burns' Anat. of Head and Neck, 

1823. 
Burns'Anat. of Head and Neck, 

1823. 
Maryland Medical Recorder, 

vol. i. 
Journ. de Physiologie, torn. vii. 

N.Y. Med.&Phys. Jour., vol. v, 
N.Y. Med.& Phys. Jour., vol. v. 
N.Y. Med. & Phys. Jour. , vol. v. 

Lancet, vol. xii. 

Lancet, vol. xii. 



Lond. Med. and Phys. Journ., 

vol. v., N. S. 
Jour, de Physiologie, torn. vii. 

Lancet, vols. xii. and xiii. 

Glasgow Med. Jour., vol. i. 

Jour. Univers. Hebdom., torn. 

iii. 
On Tumoi-s. 
Med. Chirurg. Bulletin, vol. i. 

Amer. Jour, of Med. Sci., vol. 

xii. 
Med. Quarterly Review, vol. i. 

Boston Med. and Surg. Jour., 

vol. xx. 
Med. Operatoire, torn, ii., 1S39. 

Gabe on Aneurismal varix, 

1844. 
Med. Chirurg. Trans, vol. xxii. 
Med. Chirurg. Trans, vol xxii. 
Lond. & Edin. Monthly Jour., 

vol. ii. 
Revue Medicale, 1S38. 

Revue Medicale, 1838. 

Gazette Medicale, 1840. 

London Medical Gazette, vol. i., 
1842-3. 

Gazette Medicale, 1S40. 

Boston Med. and Surg. Jour., 
vol. xxiv. 

Transactions of College of Phy- 
sicians of Philada., 1S42. 

Amer. Jour, of Med. Sci. vol. x., 
N.S. 

Lancet, 1S44. 

New York Jour, of Medicine, 
vol. v. 



Archives Centrales, 1S45. 
Gazette Medicale, 1816. 



260 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Series VI. — Brasdor's Operation. 











Right 




Date of 


Re- 


Period 


Cause of 




■ 


Surgeon. 


X 


6 


or left 


Disease. 


opera 


suit. 


of 


death. 


Work. 


fc 




CD 


< 


side. 




tion. 




death 






] 


Wardrop 


F. 


75 


Right 


Aneurism of 
root of carotid 


June, 
1825 


Roco- 
vered 


.... 


.... 


On Aneurism 


2 


Wardrop 


M. 


57 


Right 


Aneurism of 
root of carotid 


Dec. 10, 

1S26 


No 

im- 
prove- 
ment 






On Aneurism 


3 


Lambert 


F. 


49 


Right 


Aneurism of 
root of carotid 


March 
1, 1827 


Reco- 
vered 








On Aneurism 


4 


Bush 


F. 


36 


Right 


Aneurism of 
root of carotid 


Sept. 11, 

1827 


Reco- 
vered 





.... 


On Aneurism 


5 


Evans 


M. 


30 


Right 


Aneurism of 

arteria innonii- 

nata and root 

of carotid 


July 22, 

1828 


Reco- 
vered 






Villardebo 
These 


8 


Mont- 
gomery 


M. 


40 


Left 


Supposed 

aDeurism of 

carotid 


March 
10, 1829 


Reco- 
vered 






Med. Chirurg. 

Review, 
Jan. & April, 
1830 


7 


Mott 


M. 


51 


Right 


Aneurism of 

arteria inno- 

minata 


Sept 26, 
1829 


Reco- 
vered 


.... 


.... 


Am. Journ. of 

Med. Sci., vols. 

v. & vi. 


8 


Wick ham 


M. 


55 


Right 


Aueurism of 

arteria inno- 

minata 


Sept. 26, 
1829 


Reco- 
vered 


.... 


.... 


Lancet, 1840 


9 


Key 


F. 


61 


Right 


Aneurism of 

arteria inno- 

minata 


July 20, 
1S30 


Died 


A few 

hours 

after 

operat'n 


want ofam't 
of Mood ne- 
cessary to 

innervation 


Lond. Med. 

Gazette, 

July, 1830 


]0 


Morrison 


M. 


42 


Right 


Aneurism of 

arteria inno- 

miuata and 

root of carotid 


Nov. 8, 
1832 


Reco- 
vered 






Am. Journ. of 
Med. Sci., 
vol. xix. 


11 


Fearn 


F. 


2S 


Right 


Aneurism of 
theinnominata 


Aug. 30, 
1836 


Reco- 
vered 


.... 





Lancet, 1836-8 


12 


Colson 


F. 


63 


Left 


Aneurism of 
root of carotid 


1839 


Reco- 
vered 






Gaz.Medicale, 

Sept. 1810, & 

Mems. French 

Acad., 1811 


13 


Fergusson 


M. 


56 


Right 


Aneurism of 

arteria innomi- 

nata & root of 

subclavian 


June 22, 
1841 


Died 


7th day 


Pleuro- 
pneumonia 


Am. Journ. of 

Med. Sci., 
vol. iii., N.S. 


14 


O'Shaugh- 
nessy 


M. 


42 


Right 


Aneurism of 
aorta, supposed 
to be of the root 
of carotid and 
innominata. 




Died 


10th day 


Rupture of 
aorta 


Gaz. Medicale, 
No. xviii.,1843 


15 


Campbell 


M. 


4S 


Right 


Supposed 
aneurism of 
arteria inno- 
minata 


March 
8, 1845 


Died 


19th day 


Pneumonia 


Lond. & Edin. 

Monthly Jour. 

1S45 



REMAKKS. 

1. Progressive diminution of tumor after operation till the 5tli day, when 
it increased, inflamed, suppurated, and ulcerated. Upwards of three years 
after the operation the patient continued to enjoy good health. 

2. Tumor did not diminish after operation. About three weeks after it 
the swelling increased, and its pulsations became stronger. Patient died 
March 23, 1827. On dissection the heart was found hypertrophied. The 
carotid artery was found to be completely perviotis, and could hardly have 
been tied. 

3. Tumor diminished in size, and finally entirely disappeared. Five 
weeks after operation the wound, which had healed, re-ulcerated. April 18, 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 261 

hemorrhage from wound, which was repeated at intervals till 23d ; again 
on 1st of May, when she died. On dissection pericarditis and dilatation 
of aorta. Sac filled with coagulnm. Carotid thickened, and lower part of 
it completely closed. Just above where the ligature was applied an ulcerated 
opening of it existed. 

4. The tumor was very large and suffocation imminent. After the ope- 
ration it rapidly diminished. On 27th day after it the wound was healed, 
and the tumor was reduced to one-half its former bulk. Patient was alive 
and well in March, 1830. 

5. Pulsation stronger on 23d. By 22d October tumor had diminished 
one-third, was hard, and pulsation scarcely perceptible in it. On 8th Au- 
gust, 1830, tumor suppurated and discharged about oz. xxiv of pus mixed 
with a number of hairs. The opening was enlarged, and two fleshy tumors, 
of the size of a small pullet's egg, were brought into view by it, having on 
their surface several hairs analogous to those which had been discharged. 
A ligature was put around that which first presented, as low as possible be- 
hind the sternum, and it was allowed to slough off. The second was also 
tied, and then removed by the knife close to the ligature. After this the 
cavity of the sac contracted, and by end of November was completely cica- 
trized. On 16th May, 1831, she enjoyed perfect health, and all trace of 
tumor had disappeared. 

6. By 14th March the tumor was reduced to half its size, but on 28th 
again enlarged, and on 29th May gave way and discharged oz. viij of dark 
fetid fluid. On following day the opening was enlarged and gave exit to 
coagula. On 3d July expectorated oz. vj of fluid blood, and died on 12th. 
Dissection showed no vestige of sac remaining. Left carotid was obliterated 
from the bifurcation to aorta. A distinct aneurism of aorta, of the size of 
an orange, existed between the arteria innominata and the left carotid. 

7. The pulsation in and size of tumor gradually diminished after the ope- 
ration, and by 16th of October both had entirely disappeared. The patient 
died from suffocation April 22, 1830. Dissection showed the right carotid 
to be obliterated. No tumor externally, internally was of the size of the 
two fists. 

8. Immediately after the operation the tumor grew less, and the pulsation 
in it diminished. In December the tumor was increasing rapidly, and was 
more than double its original size, and on the 3d of that month the subcla- 
vian was tied. This operation was followed by relief of symptoms, but the 
tumor continued slowly to increase. He died 16th Feb. 1840, from burst- 
ing of the sac. Dissection showed the aneurism to be seated in the innomi- 
nata. The aorta was dilated and studded with osseous plates. 

9. On autopsy found aneurism of the innominata and of the cross of the 
aorta. The left carotid was almost obliterated, and the vertebrals smaller 
than in the natural state. 



ti 



262 CONTRIBUTIONS TO PRACTICAL SURGERY. 

10. Afternoon of operation pulsation in the tumor "was tremendous. " 
After the 17th it became weaker, and tumor began to harden and diminish 
in size. He returned to his employment (charcoal maker), and dropped 
down dead 20 months after the operation. The arteria innominata was 
double its natural size, and studded with spiculse of ossific matter. Eight 
carotid, from its origin to point at which ligature had been applied, was 
dilated into a sac, which was plugged up by a dense fibrinous deposit. 

11. By 9th Sept. tumor had lessened considerably, and the pulsations 
were less distinct, and on 19th of same continued gradually diminishing. 
Two years after operation there was no appearance of tumor externally, 
but in consequence of a return in her symptoms a ligature was put round 
the subclavian (Aug. 2, 1838). From this she recovered, and her symp- 
toms were mitigated. She died Nov. 27, 1838, of pleuritis, having lived 
two years and three months after ligature of the carotid. Dissection showed 
the innominata alone to be the seat of disease. The sac, except a channel 
of the usual size of the innominata, was filled by a dense, organized coagu- 
lum. The right carotid was permeable for about a third of an inch from its 
origin. Opposite the cricoid cartilage there was an interruption to its con- 
tinuity, where the ligature had been applied. The upper portion of the 
vessel was impermeable to where the external carotid was given off. 

12. Pulsation in tumor gradually diminished after operation. One year 
after it was the size of a small nut, and pulsation was scarcely perceptible 
in it. M. Robert, in his These, states, that in June, 1842, the patient con- 
tinued in a satisfactory state. 

13. After the operation the tumor decreased, and its pulsations were 
weakened. On dissection the tumor was nearly filled with pretty firm clots 
of fibrin. No clot was found in the carotid even as high up as the ligature, 
which was placed one-fourth of an inch below the bifurcation. 

14. Tumor did not diminish after the operation. On dissection the caro- 
tid was found obliterated, both above and below the ligature, by a firm clot. 
The ligature had been placed three-fourths of an inch below the bifurcation. 

15. On tightening the ligature the swelling disappeared. After a short 
time it began gradually to return, though it did not nearly regain its original 
size. On 11th the tumor was the size of a walnut. Dissection showed the 
tumor to fill up the whole of the anterior and middle mediastinum in front 
of the root of the right lung, extending from the cartilage of the third rib to 
the top of the sternum. The aneurism commenced at root of innominata, 
involving nearly the whole of that vessel, and also the transverse portion of 
the arch of the aorta as far as the left carotid. The first bone of the sternum, 
end of clavicle, and first rib were denuded of periosteum, and formed part 
of the outer wall of the sac. Descending aorta was dilated as far as the 
diaphragm, and had ossified deposits. Left ventricle slightly hypertrophied. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 263 

Series I. — Aneurisms. 

Mortality. — Of the thirty -eight cases in this series, twenty- 
two recovered, and sixteen died. 

Sex. — Of these thirty-eight cases, twenty-seven were males, 
and eleven females. Of the eleven females, two had aneurisms 
following wounds, seven labored under true aneurisms, and 
two had tumors in the neck which were mistaken for it. 

Right or left side. — Of thirty-three cases in which the 
affected side is noted, twenty-two were on the right, and 
eleven on the left side. 

Age. — This is mentioned in thirty-four of the cases, of 
which number there were under 20, four; between 20 and 30, 
seven ; 30 and 40, eight ; 40 and 50, nine ; 50 and 60, three ; 
60 and 70, three. 

Disease. — Of the thirty-eight operations contained in the 
series — thirty-three were done for the cure of aneurism — one 
was for the cure of varicose aneurism, and in four the tumors 
though supposed to be aneurisms were afterwards discovered 
not to be such. 

Period the ligature separated. — In twenty -one of the cases in 
which this is noted, the ligature came away : in thirteen, 
before the twentieth day ; in seven, between the twentieth and 
thirtieth days; and in one on the thirty-third day. 

Return of pulsation in the tumor after the application of the 
ligature. — In nine of the thirty-eight cases, pulsation was 
noticed in the tumor after the operation. In one of these 
(No. 2), pulsation "did not wholly cease" after the application 
of the ligature, but continued for upwards of two months, 
the cure afterwards being perfect. In No. 10, pulsation 
became more faint, but did not entirely cease on tightening 
the ligature. Two days afterwards it was not perceptible, and 
the swelling diminished to one-fourth of its original size. In 
No. 13, the tumor was noticed to pulsate on the fourteenth 
day after the operation, and continued to do so four or five 
months. In JNTos. 23, 28, and 33, pulsation never entirely left 
the tumors. In the first of these, aneurisms existed on both 
sides of the neck. Pulsation did not immediately cease on 



264 CONTRIBUTIONS TO PRACTICAL SURGERY. 

the application of the ligature, though it did in the course of 
the following hour; on the succeeding day, however, it re- 
curred feebly, and continued diminishing till the seventeenth 
day, but never ceased. The patient recovered from the effects 
of the operation. The second died after repeated hemorrhages 
at the end of six weeks. The last (No. 33), was a woman 
aged sixty, affected with aneurism of the internal carotid. 
The tumor which had existed about five months, and had 
attained the size of a large walnut, was in the throat in the 
situation of abscess connected with the tonsil. It presented 
the diffused aspect of a purulent collection, and a strong and 
uniformly distending pulsation could be perceived over every 
part of it. After the artery was tied, pulsation continued in 
the tumor, but was much less forcible. The patient died in 
thirty hours. The operator adds, "though doubts might be 
entertained as to the cure of the disease, through want of suf- 
ficient obstruction in the flow of blood, no apprehension was 
entertained of danger from the operation, and I feel quite 
unable to offer any satisfactory explanation of its fatal issue." 
This case is highly interesting, as presenting an example of 
aneurism in a very unusual situation, and is accompanied by 
a drawing which shows very distinctly its position in regard 
to the artery. In No. 9, pulsation was observed in the tumor 
four hours after the operation and left it on the sixteenth day. 
In No. 15, pulsation in the tumor continued for a number of 
weeks — a cure taking place, and in No. 32, slight pulsation 
returned on the night of the operation, but afterwards entirely 
disappeared. 

Hemorrhage after the operation. — All the cases in which this 
occurred, after the operation, but two proved fatal. In No. 
12, the artery was tied on the 14th of November, and the 
hemorrhage had place on the 29th of December, and was 
arrested by firm pressure and low diet. In No. 38, it took 
place on the evening of the tenth day, to the amount of a pint, 
and was checked by pressure, but on the next day there was 
a recurrence of it, which ceased spontaneously. 

Bursting of the tumor. — In six of the thirty-eight cases, the 
tumor suppurated, and either burst spontaneously or was laid 
open. Of these, four died, and two were cured. In No. 5, 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 265 

the opening in the sac took place nearly eight months after 
the operation, and in No. 9 there was an interval of about 
four months between these occurrences. In one case, which 
died, No. 36, the opening was in the pharynx fifteen days 
after the operation, and on the same day the tumor was laid 
open. In No. 27, the aneurism had ruptured into the mouth, 
previous to the operation, yet the patient did well. 

Cause of death. — Of the thirty-eight cases operated upon 
for aneurisms, sixteen died. Of these, two died from inflam- 
mation of the sac; one from inflammation of the brain ; five 
from hemorrhage coming on at periods between the fourth 
and seventieth days ; one from spasm of the glottis ; two from 
apoplexy and congestion of the brain ; one from " exhaustion" 
on the fifth day ; and in four the cause of death is not noted. 

Mistakes in diagnosis. — In seven of the thirty-eight cases 
in the table, mistakes in diagnosis occurred. .In No. 16, the 
tumor, on dissection, proved to be a fungus hsematodes. In 
No. 37, the disease was carcinomatous. In No. 30, the aneu- 
rism was supposed to be cured, the patient living nine months 
after the operation, but on post-mortem examination, it was 
found to be a tumor surrounding, though in no way connected 
with the artery. In No. 35, the patient was also looked upon 
as cured of his aneurism, and died four months afterwards of 
bronchitis, when the disease was found to be a glandular 
swelling. In No. 25, the aneurism was mistaken for an abscess, 
and incised ; repeated hemorrhages followed, and the external 
carotid was secured. This procedure failed to arrest the 
bleeding, and the common carotid was tied. The patient died 
on the sixth day. In No. 31, a boy nine years of age, the 
tumor was carefully examined to ascertain if pulsation existed, 
" a hint having been given that it might in some way be con- 
nected with the carotid," but not the slightest pulsation could 
be perceived in any part, except in the course of the vessel. 
Such being the case, a puncture was made in the tumor under 
the impression that it contained matter. A gush of arterial 
blood followed, and about four ounces were lost in a few 
seconds. The wound was closed by hare-lip pins and the 
twisted suture, and the bleeding checked. On the following 
18 



266 CONTRIBUTIONS TO PRACTICAL SURGERY. 

day the carotid was tied close to the origin of the innominata. 
On the 3d of November, a sudden gush of arterial blood took 
place from the wound in the neck, the ligature being still firm. 
This was suppressed by plugging the wound with lint. Hem- 
orrhage recurred six times after this, the last leaving him in 
a state of perfect collapse, and he died on the 5th. On dis- 
section, the proximal end of the vessel was found to be quite 
open, and there had been no attempt at the formation of a 
clot. The operator, Mr. Liston, believes that the tumor was 
originally a scrofulous abscess accompanied with ulceration 
of the vessel, and consequent effusion of blood into the cyst ; 
this, he thinks, was proved by the position and form of the 
cyst (plates of which are given), the nature of the lining 
membrane, the absence of lamellated coagula, and the kind of 
opening in the artery — it being very small, and the three 
coats being traceable to the margin of it. No. 22, was an 
aneurism following a wound of the vertebral artery alone, in 
which the common carotid was tied at the hospital of Naples. 
The tumor was seated below the mastoid process. The patient 
died on the ninth day, and the autopsy showed the aneurism 
to occupy the vertebral artery between the transverse pro- 
cesses of the first two cervical vertebras. The vertebral 
artery being very rarely the seat of aneurism, it may be well 
to notice here a case somewhat similar to that just mentioned, 
which is recorded by M. Kamaglia, of Naples. The patient, 
aged thirty-nine, received a wound from a sharp-pointed in- 
strument behind the left ear, which resulted in the formation 
of an aneurismal tumor in that situation. The common 
carotid was tied for its cure, but finding that this did not 
arrest pulsation in the tumor, the ligatare was removed. A 
short time after, the patient died, and dissection showed the 
aneurism to arise from the vertebral artery. 1 

Another example of aneurism of the vertebral artery is 
mentioned by Mr. South, in his translation of Chelius's 
Surgery, as having occurred in the Northern Infirmary 
at Liverpool ; the carotid artery could be distinctly traced 

1 Velpeau, Med. Operat., torn. ii. p. 220. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 267 

over the pulsating swelling, of the actual nature of which 
there were some doubts as to what kind of aneurism it was, 
or whether only a pulsating tumor. It was decided to tie the 
common carotid artery. The tumor rapidly increased after 
the operation, and in about a fortnight the patient died by the 
bursting of the aneurism into the trachea. On post-mortem 
examination, an aneurism of the vertebral artery, between 
the transverse processes of the fourth and fifth cervical ver- 
tebras, was found. 

The diagnosis of aneurismal tumors of the neck is acknowl- 
edged by all to be at times exceedingly difficult. An instance 
in which enlargement of the thyroid gland, as proved by 
dissection, was mistaken for an aneurism, has been reported 
by the late Dr. S. P. Griffitts. Wishing, he observes, "to 
think the disease was glandular, endeavors were frequently 
made to draw the tumor out from the artery, but without 
success, as it was so firmly fixed over the vessel as not to be 
moved from it, and the pulsation was such as to convey the 
idea that there was no intervening substance." The propriety 
of an operation had been suggested, to which objection was 
made from a belief that the artery below the clavicle was 
diseased. In the Dictionnaire des Sciences Mediccdes, torn, xviii., 
the case of a Creole with a tumor in the neck is mentioned, 
which was submitted to the inspection of several celebrated 
surgeons in America, Paris, and London ; all of whom pro- 
nounced it to be an aneurism of the carotid artery. It was 
afterwards ascertained by M. Boyer, that no such disease 
existed — but simply an extensive enlargement of the glands 
of the neck. 

Derangement of the cerebral functions. — In twelve of the 
thirty-eight cases, serious symptoms were manifested in the 
brain after the ligature. The effect of cutting off the supply 
of blood through one of the carotids is so interesting, and 
until the researches of Mr. Chevers, of London, 1 was looked 
upon so lightly by practical surgeons, that we shall give these 
results somewhat in detail. In the first case in which the 

1 The paper of this gentleman will be found in the London Medical 
Gazette, vol. i., K S., 1845. 



268 CONTRIBUTIONS TO PRACTICAL SURGERY. 

operation was ever done for the, cure of aneurism, No. 1, para- 
lysis of the left arm and leg came on on the eighth day. Four 
days afterwards, the palsy of the arm had almost disappeared, 
and no further report concerning it is made. In No. 4, there 
was great drowsiness on the third day, and, on the following 
day, the right side was much more feeble than the left. After 
some days these symptoms gradually disappeared. In No. 
18, the patient became slightly convulsed on the right side, 
one and a half hours after the operation, and sunk into a 
state of stupor. Two days afterwards, his left side became 
paralyzed. In No. 16, it is stated, that "a few hours after the 
operation, symptoms of inflammation of the brain arose," but 
were subdued by the atiphlogistic treatment. In No. 37, 
apoplexy occurred on the morning of the day following the 
operation, from which the patient partially recovered, and 
lingered on for nine days after it. In No. 35, slight cerebral 
disturbance arose the day after the ligature, and on the fourth 
day there was paralysis of the left side. In No. 17, dimness 
of vision, and a sense of coldness over the right side of the 
face, came on immediately after the operation, which gradu- 
ally disappeared in a few hours, though for some days, head- 
ache, difficulty of deglutition, and heaviness in the right side, 
were complained of. In No 20, the patient lost the use of the 
left eye, and was affected with hardness of hearing. In No. 
25, there were slight convulsions on the second day after the 
operation. In No. 9, giddiness, with numbness and trembling 
of the right arm, came on two hours after the operation, the 
numbness disappeared the day after. In No. 34, hemiplegia 
followed (the side is not stated), which, it is added, may have 
occurred at the moment of tying the ligature, but was not 
remarked until an hour or more after the operation, and the 
patient continued faint and hemiplegic till her death on the 
fifth day. In No. 26, coma supervened on the night after the 
operation, and the patient soon after died. Of these twelve 
cases, seven died. 

These cerebral symptoms were noticed at various intervals 
after the tying of the artery, and in all of them, are attribu- 
table either to cutting off the direct supply of blood to the 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 269 

brain, or to disease consequent upon the altered condition of 
the circulation in that organ. It is impossible to determine 
what particular state of the vessels of the brain predisposes 
it to become diseased after obliteration of the carotid. The 
researches of Mr. Chevers lead him to think that in most 
instances the fatal mischief is consequent upon deficient arte- 
rial supply, but that in some cases it may arise from increased 
pressure of blood upon the arteries of the affected hemisphere, 
in consequence of the supply to the carotid being diverted 
through the vessels of the circle of Willis. 

Series II. — Wounds, etc. 

Of the thirty cases contained in this series, fifteen were 
cured and fifteen died. 

Period the ligature separated. — In thirteen cases in which 
this is noted the ligature came away: in one, before the tenth 
day; in nine, between the tenth and twentieth days, and in 
three, between the twentieth and thirtieth days. 

Hemorrhage after the operation. — In six cases hemorrhage 
followed at various intervals after the application of the liga- 
ture, and of these three died. 

Derangement of the cerebral functions. — In eight of the 
thirty cases in this series, serious cerebral symptoms occurred, 
either from inflammation or from interruption to its normal 
circulation, and of these eight only two recovered. In one 
of them, No. 16, the operation was followed by troubled 
vision, which remained imperfect on the right side. In No. 
18, immediately after the application of the ligature, the 
patient became motionless, lay with closed eyes without an- 
swering when spoken to, unless the questions were repeated 
several times. This state was followed by coma and death in 
twenty-four hours. In No. 6, headache and delirium occurred 
on the fifth day after the operation, and on the seventh, stupor 
and death. In No. 14, it is stated that she lay for two or 
three days subsequent to the operation in a state of insensi- 
bility, and then gradually recovered. In No. 26, hemiplegia 
of the left side of the body and right side of the face was 
observed three hours after the operation, and the patient died 



270 CONTRIBUTIONS TO PRACTICAL SURGERY. 

on the ninth day. In No. 2, the man, on the night of the 
operation, became delirious and had convulsions which were 
most violent on the left side, and soon afterwards his right 
side became hemiplegic. In No. 22, hemiplegia of the left 
side came on on the sixth day. In No. 29, the patient during 
the operation made violent efforts with his right side, but 
never moved the left extremities. During the night the right 
extremities were frequently convulsed. In the two following 
days twitchings of the right side and paralysis of the left 
continued. 

In No. 12, it is noted that the patient was epileptic, and 
that this condition was not removed by cutting off the supply 
of blood to the brain. In No. 19, the patient during the 
operation " became relaxed and seemingly faint, and his 
voice, which had been previously coarse, fell to a whisper 
and could not be raised above it." The respiration was not 
disturbed. The operator attributes the feebleness of the voice 
to " turning off the supply of blood to the larynx through 
the upper thyroid artery," though it would seem more pro- 
bable that, in the necessary hurry of this operation, and 
the obscurity of parts from the flow of blood, the superior 
laryngeal nerve had been included in the ligature. In No. 
9, the vessel was secured to arrest hemorrhage following the 
extraction of a tooth, styptics and the actual cautery having 
been first in vain tried, but the bleeding continued after the 
vessel was tied. 

In No. 26, a mistake occurred in regard to tying the artery 
which merits notice. On the fifth day after the receipt of the 
wound in the side of the neck, the surgeon in attendance tied 
what was supposed to be the primitive carotid; compression, 
which had before been employed, was continued. Three days 
after hemorrhage returned as severely as ever, and M. Sedillot, 
who was then consulted, finding that the ligature had really 
not been placed around the artery, proceeded to secure it. 

A most instructive case, in which an error similar to that 
just mentioned was made, occurred at the New York Hospital 
in 1840. The case was one of violent hemorrhage* arising 
from ulcerations towards the middle of the neck, in which it 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 271 

was determined to apply a ligature to the common carotid. 
An incision was made in the ordinary manner on the inner 
side of the sterno-mastoid muscle, and in the usual situation 
of the sheath of the vessels a large mass of fibrine was found 
adhering to all the tissues in that region and confounding 
them in such a manner, that it was difficult to distinguish one 
from another. After careful dissection, what appeared to be 
the sheath of the vessel was exposed and divided. A cylin- 
drical body of the size and color of the artery was then 
brought into view, and a ligature passed under it. Several 
of the surgeons present, as well as the operator, felt the vessel 
under which the ligature was placed and were convinced 
that it was the carotid artery, although no distinct pulsation 
could be felt in it; this was attributed to the extreme prostra- 
tion to which the patient was reduced. The ligature was then 
tied without any effect in arresting the flow of blood. From 
this it seemed evident that the subclavian, or one of its 
branches, was wounded, but the patient was so prostrated that 
it was not deemed safe to attempt any further operation. 
Firm pressure with the hand was therefore continued. Death 
occurred early on the following day. Upon post-mortem ex- 
amination, the ligature was found to embrace only a band of 
organized lymph, situated immediately anterior to the sheath 
of the vessels, which were in a perfectly healthy condition. 
The hemorrhage was found to proceed from the inferior thy- 
roid, which was destroyed by ulceration in one-half of its 
circumference for the space of an inch. 1 

Series III. — On Extirpation of Tumors. 

In this series, there are eighteen cases in which the common 
carotid was tied previous to, or at the time of the extirpation 
of tumors of the neck or jaw. Of these, six died, and one is 
stated to have been " recovering on the eighth day." 

In one of these, the external jugular vein was wounded in 
exposing the artery (No. 16). In No. 15, where the artery of 
the right side was secured, the patient had, on the evening of 
the operation, " not exactly paralysis, but great difficulty in 

1 New York Medical Gazette, Feb. 9, 1842. 



272 CONTRIBUTIONS TO PRACTICAL SURGERY. 

moving the left arm and leg." On the seventh day, " incipient 
coma, loss of sensation and motion in the left arm" is noted, 
and on the day after sensation and motion in the arm are said 
to have returned. No further account is furnished. In No. 
10, the patient is stated to have been seized with convulsive 
action of the muscles of the whole body, but chiefly on the 
left side, on the morning after the operation, and on the suc- 
ceeding day was suddenly taken with convulsions, soon be- 
came comatose, and died. 

The ligaturing of the carotid, previous to the extirpation of 
tumors about the neck or face, originated with Mr. Goodlad. 
Unless there is reason to suppose that the tumor involves the 
artery itself, it would seem to be an unnecessary step, inas- 
much as pressure alone, if confided to a careful assistant, will 
as effectually guard against the danger from hemorrhage. In 
determining whether or not it is to be employed, it must be 
borne in mind that this preliminary measure is in itself a 
dangerous operation, and as has been justly remarked by Mr. 
Chevers, that " it would be far better for the surgeon to make 
up his mind to contend with an active hemorrhage, than that 
he should submit his patient to the chance of fatal hemiplegia, 
even although he believed that chance to be a remote one." 
The idea seems still to be entertained by some, that after such 
a step, the subsequent dissection of the tumor is nearly blood- 
less. The opinion is an erroneous one, the anastomoses being 
so free in the enlarged state of vessels which usually exist in 
these cases, as at times to pour out blood profusely. In 1827, 
Mr. Lizars attempted to remove the superior maxilla for a 
medullary tumor of the antrum. He commenced by tying 
the common carotid artery of the affected side, but was pre- 
vented from completing the operation by hemorrhage, the 
patient having lost upwards of two pounds of blood in a few 
seconds. In a case which occurred to Dr. Mott where the 
carotid was tied immediately before a disarticulation of one- 
half of the jaw, the hemorrhage was exceedingly profuse, and 
some fifteen or twenty vessels required to be tied. Where 
the ligature is applied to the artery, any number of hours, or 
days, as has been done, before the removal of the tumor, the 
procedure cannot, we think, be justified. According to Mott 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 273 

and Stedman, another advantage besides that of arresting 
hemorrhage is to be derived from it, viz., that of being an 
important means of preventing inflammation in the wound. 
Facts might be adduced to show this view to be erroneous — 
the inflammation being no greater where the artery is not 
secured, than where it is tied. 

The difficulties and immediate dangers of exposing the 
carotid vessel too, in cases of large tumors, are not to be set 
down lightly. Roux, as dexterous an operator as any of his 
age, was fifteen minutes in securing the artery. Goodlad 
found it a very difficult matter to accomplish, in consequence 
of the nearness of the tumor. In a case operated upon by 
Dr. Mott, notwithstanding the patient was recumbent, and 
very little blood was lost, she became pale and almost pulse- 
less during and immediately after the tying of the carotid, 
and her mind became perturbed to so great a degree that 
cordials were administered and she was put to bed faint and 
exhausted, and the removal of the tumor deferred till the fol- 
lowing day. In an operation, mentioned by Dr. Warren, of 
a similar kind, a vein was wounded in the search for the 
carotid, which permitted the entrance of air into the circula- 
tion, and gave rise to alarming symptoms, making it necessary 
to suspend the operation, which was performed a week after- 
wards without tying the vessel. As a preliminary step to the 
operations we are now considering, the general experience of 
surgeons of the present day is decidedly against the proceed- 
ing. Mr. Liston, whose success in the management of tumors 
of the mouth and jaws, face and neck, is well known to every 
surgeon, speaks on this point very emphatically. "I have 
never," says he, " found occasion to tie the carotid previous to, 
or during the operations for their removal, and I have never 
regretted omitting this supposed precautionary measure." 
A writer upon this subject, Mr. Solly, gives it as his opinion, 
that if a ligature on the carotid is of advantage in any cases 
it is only where the tumor is of large size, and of a fungoid 
character, " in fact, that it is only necessary in those cases in 
which it is not right to operate at all." 



274 CONTRIBUTIONS TO PRACTICAL SURGERY. 

Series IV. — Cerebral Affections. 
The idea of curing epilepsy by tying the carotid artery 
seems to have been founded upon the false principle, that 
this operation would diminish the amount of blood sent to 
the head, a view, however, which is manifestly incorrect, for 
though the supply sent to the brain by one of these vessels 
should be cut off, it passes in increased amount by the artery 
of the opposite side and the vertebrals. But the notion that 
epilepsy is essentially dependent on vascular excitement, it 
need hardly now be said, is in itself an erroneous one. Any 
irritation, in any part of the body, and either corporeal or 
mental, may give rise to it. Vascular excitement may doubt- 
less occasionally be its exciting cause, though even where 
this is the case any benefit resulting from obstructing the flow 
of blood through the carotid is not likely, for the reason be- 
fore mentioned, to prove permanent. As early as 1822, liga- 
ture of the carotid was done in an epileptic patient with 
wounded throat, by Dr. Boileau, and for a considerable time 
he remained without an attack, though ultimately a recur- 
rence of them had taken place. In Dr. Becton's Case, No. 2 
of the table, the patient experienced two fits during the first 
ten days that elapsed after the operation, but after this he 
returned to his former intemperate habits and bad frequent 
attacks. No. 4, who was operated upon in February, 1831, is 
stated by Mr. Preston to have continued well and free from 
epileptic attacks up to January, 1833. In No. 5, where hemi- 
plegia of the right side of twenty days' standing existed with 
the epilepsy, the right carotid was tied August 23, 1831, and 
he was discharged from the hospital September 26th, having 
had several epileptic attacks, though of a milder kind than 
before the operation. In November he was readmitted, 
having suffered much from epilepsy and headache after his 
discharge. On the fourteenth of that month, the left common 
carotid was tied, and he was discharged December 8th, his 
epileptic attaks continuing. On the 14th of February, 1832, 
he was again readmitted in a state of insensibility, and had 
been speechless for fourteen days. Under the use of purga- 
tives, a seton, leeches, etc., these symptoms gradually disap- 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 275 

peared, and in January, 1833, was still living, though three 
months before that date he had suffered from an attack of 
paralysis agitans. In an appendix to his second paper, Mr. 
Preston states, that in one case of epilepsy this operation 
" proved entirely ineffectual." The patient had suffered from 
the disease for eight years. Both common carotids were tied 
with an interval of a month, and the day following each 
operation he had an epileptic fit not differing from those he 
had previously. 

In one of the other three cases of this series (No. 1), the 
artery was tied for the cure of a neuralgic affection, the 
operator being led to perform it from noticing that pressure, 
which was accidently made on the artery, gave some relief; 
the benefit derived from it was only momentary. In Nos. 3 
and 6, it was done with a view of curing paralysis. In the 
first of these, there was loss of power and sensation in the 
left arm and left lower extremity, and at the period of his 
discharge from the hospital (twenty-first day after the opera- 
tion), the patient was able to walk about, the arm remaining 
paralytic. In January, 1833, he continued alive, and had 
regained in great part the use of his arm. In the second, No. 
6, partial loss of motion existed in the left arm and leg, the 
patient being unable to walk without support. There was 
also complete loss of vision in the right eye, and that of the 
left was impaired. The operation was done on the right side 
on the 2d of September, and on the 27th, it is stated that he 
walked five miles, the morning after which, the sight of the 
left eye was less perfect and his head hot. He was slightly 
salivated, blistered between the shoulders, and took iodine, 
but without benefit. The diminution of the vision being now 
attributed to a return of the affection of the brain, for which 
the first operation had been done, the left common carotid 
was tied on the 10th of October. On the 11th of November 
he was dischared from the hospital, the vision remaining im- 
perfect, though in other respects he was well. 

The results of these cases we have thought it right, as matter 
of history, to give somewhat in detail. It need hardly be 
observed that quite as much, if not more, benefit as was pro- 
duced in these cases, is daily seen to follow any well-directed 



276 CONTRIBUTIONS TO PRACTICAL SURGERY. 

treatment in cases of epilepsy and paralysis, and this without 
a resort to means which endanger life, indeed by hygienic 
treatment alone. 

Series V. — Erectile Tumors. — Tumors of Diploe, Jaw, 
Maxillary Sinus, and Neck. 

In this table there are forty-two cases in which the carotid 
has been tied with the view of arresting the flow of blood to 
the tumor, and thus curing or arresting the growth of erectile 
tumors situated upon the head or face, or of firm tumors of 
the jaw, maxillary sinus, or neck. Of these forty-two cases, 
thirty-one were for the cure of erectile tumors, or arterial 
varices seated upon the head or face, of which number eighteen 
were cured, eight died, and five recovered from the effects of 
the operation without being cured. One of these latter, No. 27, 
was operated upon by the ancient method five years after lig- 
ature of the carotid, and cured; another, No. 24, is stated at 
the date of the report, two months after the operation, to have 
the tumor flattened and reduced to one-third of its former 
volume ; in a third, No. 4, all pulsation in the arteries ceased, 
though the erectile tissue continued unchanged, and pressure 
was resorted to in its after-treatment; in the fourth, No. 42, 
galvano-puncture was tried after the ligature of the vessel, 
but without benefit; and the fifth is the case of Yelpeau, 
which is detailed in another place. 

Of the eleven cases in which it was done to cure or arrest 
the growth of other tumors, five died, four recovered from it 
but were not cured, and two are stated to have been cured, 
though in one of them, No. 5, part of the tumor was removed 
by the knife after the operation, and caustics ultimately were 
made use of to destroy it. 

The treatment of purely erectile tumors by cutting off the 
supply of blood to them, by the application of a ligature to 
the main artery, originated with Pelletan, and has often, as 
will be seen by the above results, proved successful in the 
carotid — more frequently, we may add, than in other situa- 
tions. In some instances, though it has failed to make a per- 
fect cure, yet it seems to have so diminished or retarded the 
progress of the disease, as to have allowed a resort to ex- 






MORTALITY FOLLOWING LIGATURE OF ARTERIES. 277 

cision, the ligature, or pressure, which without it, would have 
been either more dangerous or altogether inapplicable. 

The facts recorded show that ligature of the carotid to 
diminish non-erectile growths of the face, jaws, or neck has 
proved altogether ineffectual where it has been alone depended 
upon, and cannot at this day be countenanced by sound 
surgery. 

A summary of the whole number of cases contained in 
this series furnishes the following results : — 

Mortality. — Of the forty-two cases, twenty were cured, 
thirteen died, and nine recovered from the operation, though 
not cured by it. 

Right or left side. — In thirty -nine of the cases in which the 
side is noted, nineteen were on the right side and twenty on 
the left. 

^e.— This is given in thirty-four of the cases, of which 
number there were under 20, sixteen ; between 20 and 30, 
eleven ; 30 and 40, four ; 40 and 50, two ; aet. 66, one. 

Period the ligature separated. — In twenty-three of these cases 
in which it is noted the ligature separated ; in three, before 
the tenth day ; in eleven, between the tenth and twentieth 
days ; in six, between the twentieth and thirtieth days ; and 
in three, above the thirtieth day. 

Return of pulsation in the tumor after the application of the 
ligature. — In ten of the cases of erectile tumors, more or less 
thrill of pulsation was noticed in the tumors after the appli- 
cation of the ligature. In six of these cases, the disease was 
situated in the orbit, and in the other four, on the face or 
head. The case of M. Yelpeau (No. 35) is so rare and inter- 
esting a one, that I annex some of the details of it. The 
patient was affected with tumors in both orbits, offering all 
the signs characteristic of erectile tissue, and that on the right 
side was large and projecting. Compression of the right 
primitive carotid arrested completely the pulsation and thrill 
in the tumor of the left orbit, and incompletely in that of the 
right, while pressure on the left carotid put a stop completely 
to all pulsation in the tumor of the right orbit, and but in- 
completely in that of the left. After the right artery was 
ligatured the tumor of the left side ceased to pulsate; the 



278 CONTRIBUTIONS TO PRACTICAL SURGERY. 

tumor of the right side shrunk, but- pulsation could still be 
perceived in it. At the end of ten days, all pulsation had 
ceased, and the patient appeared to be cared. He remained, 
however, in the hospital for six weeks, and during this in- 
terval it became evident that the cure was not perfect, pulsa- 
tion having reappeared by degrees in the tumor of the right 
side. In February, 1840 (about six months after the opera- 
tion), he remained in nearly the same state as he was six 
weeks after it, and at that date, compression of the carotid 
of the left side arrested both the pulsation and thrill in the 
tumor of the right orbit. Ligature of the last-named artery 
was at this period proposed, but was refused by the patient. 

Hemorrhage after the operation. — This occurred in six cases, 
four of which terminated fatally. In No. 6, bleeding from 
the wound in the neck took place on the twenty-third day, 
was repeated several times, and ceased spontaneously ; in ISTo. 
2, hemorrhage from the lower part of the wound occurred'and 
also ceased spontaneously. 

Cause of death. — Of the forty-two cases in this series, thirteen 
died. Of these, one -died from ulceration of the tumor; four 
from hemorrhage; one, from convulsions; one, from inflam- 
mation of the brain; one, from phlebitis of the internal jugu- 
lar ; one, from lock-jaw ; one, from inflammation of the chest ; 
two, from long-continued constitutional disturbance occasioned 
by disease ; and one from apoplex}'. 

Derangement of the cerebral functions. — In eight of the forty - 
two cases, very serious symptoms of affection of the brain 
were manifested after the ligature of the vessel. In No. 4, a 
sense of numbness in the left thoracic member came on the 
evening of the operation which disappeared on the second 
day. In No. 10, some fever with delirium and paralysis of 
the left side of the face and hand appeared on the third day. 1 
In No. 17, convulsions and paralysis of the right arm came 
on on the sixth day, after recovery from which, at the end of 
three months, her intellect remained enfeebled ; the disease 
for which the operation was done being but little changed. 

1 In this case it is noted that the internal jugular vein was included in 
the ligature. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 279 

In No. 18, vision of the left eye became seriously affected on 
the eleventh day after the operation, and the patient had some 
degree of deafness and delirium ; on the eighteenth day the 
eyeball was protruded and sloughed. In No. 26, complete 
hemiplegia followed the operation. 1 In No. 30, the woman 
had paralysis of the left side on the second day after the ope- 
ration. In No. 82, aged fifteen months, the child was at- 
tacked suddenly with convulsions and hemiplegia of the right 
side about a week before the complete healing of the wound 
and forty-nine days subsequent to the operation. In No. 38, 
paralysis of the left side came on the day after the vessel was. 
tied. 2 

Series VI. — Brasdor's Operation. 

Upon fifteen cases of aneurisms of the lower part of the 
neck, in which the carotid has been ligatured between the 
aneurismal tumors and the capillaries, four appear to have 
been cured (Nos. 1, 4, 5, and 12) ; six recovered from the ope- 
ration and appear to have had some relief of symptoms after 
it; four died; and in one, in which the artery probably was 
not really tied, there was no improvement. Nine of these 
fifteen operations were done for aneurisms, or cases supposed 
to be such, of the arteria innominata ; of which, five recovered 
and four died. 

Derangement of the cerebral functions. — In two of these fif- 
teen cases derangement of the cerebral functions followed the 
ligature of the carotid. In No. 5, where the right artery was 
tied, the face and whole right side of the body were partially 
paralyzed, which paralysis was only discovered when the 
patient first left his bed, three weeks after the operation. In 
No. 15, where the right carotid also was tied, the patient 
complained immediately on tightening the ligature of severe 
pain in the side of the head ; the pupil of the opposite eye 
became slightly dilated, he felt bewildered and confused, and 

1 The internal carotid was tied in this case as well as the common trunk. 

2 Another case is quoted without details in the Gazette Medicale for 1839, 
from Rust's Magazin, where the common carotid was tied by Dohlh'off to 
arrest the growth of a tumor of the palate ; paralysis of the side opposite to 
that in which the operation was practised took place a week after it, and 
was followed by death on the twenty-sixth day. 



280 CONTRIBUTIONS TO PRACTICAL SURGERY. 

could with difficulty be induced to remain quiet. On the day 
of his death, the left pupil was largely dilated. He was sen- 
sible to the last. 1 

Difficulties of diagnosis. — It is not intended in this place to 
dwell upon the difficulty of diagnosis which must often exist 
in aneurisms about the root of the neck. We shall here only 
notice that in three of the cases in our table where the root 
of the carotid or the innominata was supposed to be the seat 
of the tumor, it was found actually to have arisen from the 
aorta itself. Yelpeau, in his Medecine Operatoire, mentions 
two other cases in which the carotid was tied where similar 
mistakes in diagnosis occurred. One of these was observed 
in the civil hospital of Amsterdam, in a man affected with an 
aneurismal tumor projecting above the sternum. M. Tillanus 
believing the left carotid to be the seat of the disease, tied 
that vessel a little beyond the tumor. The patient recovered 
from the operation, but died suddenly five months afterwards, 
when the tumor was seen to arise from the arch of the aorta 
and to be completely filled with a white clot. The parts are 
shown in the pathological collection of the hospital. In the 
other case, the aneurism, which appeared to be on the point 
of bursting, showed itself as the preceding one just above 
the sternum. Looking upon it as an aneurism of the carotid, 
M. Eigen placed a ligature above the tumor on the 21st of 
February, 1829. After the operation the tumor diminished 
considerably in size, and the sufferings of the patient became 
less. On the 13th of June following, he died with symptoms 
of asthma. The autopsy showed the aneurism to have its 
origin in the arch of the aorta between the left carotid and 
the innominata, and was filled up, as in the case of Tillanus, 
by coagula. 

Ligature to both Carotids. — In a few instances, the 
carotids of both sides have been ligatured either simultane- 
ously, or with varying intervals of time between the opera- 

1 The Gazette Medicale for 1839 mentions that in an operation by the 
method of Brasdor, done for the cure of an aneurism of the innominata by 
Dohlhoff, death followed in a few days, and was preceded by symptoms of 
paralysis of the side opposite to that on which the artery was tied. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 281 

tions. Two such cases have already been noticed where the 
procedure was followed by Mr. Preston, and we shall here 
mention the other recorded cases in which it has been done. 
About the year 1823, Dr. Macgill, of Maryland, tied both 
carotids in the case of a female affected with fungous tumors 
of both orbits. Vision was destroyed, and the eyes presented 
the appearance of a confused mass protruding beyond the 
sockets. Several months after the operation, she is said to 
have been doing well, and the tumors subsiding. In a case 
of aneurism by anastomosis of the scalp, Dr. Mussey tied the 
left primitive carotid, September 20th, 1827, and on the twelfth 
day after, secured that of the right side. These operations 
failed to cure the disease, though they had the effect of re- 
ducing the tumor apparently to about one-third of its original 
volume. It was subsequent^, in consequence of its again 
enlarging and exhibiting a pulsatory movement, removed by 
excision about three weeks after the second operation. In 
this operation, which occupied more than an hour, notwith- 
standing that not more than an inch and a half of the scalp 
was divided at a time, and that immediately upon the division, 
firm compression was made upon each lip of the incision, 
while the vessels were secured by ligature, yet blood to the 
amount of nearly two quarts was lost, and the application of 
more than forty ligatures was required. The patient did well, 
and ten years after continued to enjoy good health, though, 
occasionally, he had symptoms of cerebral plethora. Lan- 
genbeck, in a case of profuse hemorrhage, coming on eight 
days after the application of a ligature to the superior thyroid 
for the cure of bronchocele, ligatured both carotids. The 
patient died on the following day. In a child four and a half 
years of age, Muller tied one primitive carotid, September 
13th, 1831, for the cure of an erectile tumor, and on the 28th 
of January, 1832, secured the other. The operation was suc- 
cessful. Kuhl, of Leipsic, in the case of a man aged 53, af- 
fected with an aneurismal tumor on the occiput, tied the left 
carotid on the 24th of May, 1834, and on the seventy-second 
day after, in consequence of profuse hemorrhage from the scalp, 
took up that of the right side. The patient was cured, though 
19 



282 CONTRIBUTIONS TO PRACTICAL SURGERY. 

lie had after-hemorrhages from the tumor which suppurated. 
During the first of these operations, the patient was seized 
with convulsions and faintings, and was removed to his bed 
in a state of insensibility ; slight convulsions also occurred 
during the performance of the second operation. Dr. Mott 
ligatured both carotids, with an interval of fifteen minutes, 
for disease of the parotid. Coma supervened, and the patient 
survived only a few hours. Dr. Ellis, of Michigan, in 1844, 
tied both of these vessels, with an interval of four and a half 
days, in a case of secondary hemorrhage, following a gunshot 
wound, and cured his patient. Dr. J. M. Warren, in a case of 
erectile tumor affecting the mouth, face, and neck, tied the 
left primitive carotid, October 5th, 1845, and on the 7th of 
November following, ligatured that of the right side. After 
this second operation, the tumor of the lip diminished one- 
half, and the fulness of the face and neck and size of the 
tongue became less. Finding that the disease did not wholly 
disappear, it was determined, on the 26th of November, to 
remove the diseased portion of the lower lip, " not less than 
two inches in length, at its free edge," by a triangular incision ; 
but previously to this, in order to avoid hemorrhage, a cata- 
ract-needle was plunged into the vascular tissue on the left 
side, and carried in different directions so as to break up and 
destroy its organization. Three days afterwards, a similar 
operation was repeated on the right side, and at the time the 
excision was made, strong compression was exercised on each 
side of the lip by means of two steel forceps prepared for the 
purpose, so as completely to intercept the course of blood 
into it. On the 12th of December the patient returned home 
well. 

Arteria Innominata. — The practicability of securing this 
vessel was suggested by Mr. Burns, in his Anatomy of the 
Head and Neck, though, as he acknowledges, "without any 
sanguine expectations of success." It was first put in prac- 
tice by Dr. Mott, in 1818, in a patient affected with subclavian 
aneurism, aged 57. The ligature, which was applied about 
half an inch below the bifurcation of the innominata, sepa- 
rated on the fourteenth day. On the twenty-third day, he 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 283 

had hemorrhage to such an extent, as to threaten instant 
death; this was arrested for the time by dry lint and a com- 
press, but after several recurrences of it he died on the twenty- 
sixth day. 1 In 1S22, Graefe tied the artery in a similar case. 
The ligature was applied about an inch above the arch of the 
aorta, and came away on the fourteenth day. After repeated 
bleedings, the patient died on the sixty-seventh day. Dr. 
Hall, of Baltimore, performed the operation, for a third time, 
in 1830. In attempting to isolate the artery, which was in a 
diseased condition, its coats gave way, and a profuse hemor- 
rhage occurred. An attempt was then made to pass the liga- 
ture by means of a needle, but the bleeding continuing, the 
wound was plugged up, and the patient put to bed. The 
patient survived until the fifth day. 2 Dupuytren states that 
a fourth operation was done at Paris, and that the patient also 
died of hemorrhage. 3 A fifth operation was accomplished by 
Mr. Norman, of Bath, in 1824, and was followed by death. 4 
In 1837, Mr. Bland operated on a sixth case, in a patient aged 
31. On the seventeenth and eighteenth days hemorrhage 
occurred, and on the evening of the latter day he died. The 
ligature was found to have encircled the artery close to its 
division into subclavian and carotid. 5 A seventh operation 
of this kind, was by Mr. Lizars, in 1837. The ligature came 
away on the seventeenth day. Several hemorrhages occurred 
after the nineteenth day, and death followed on the twenty- 
first day. Twenty ounces of coagulated blood were found on 
the right side of the chest. 6 An eighth instance of the same 
operation is given by M. Hutin. In this case, it was done to 
restrain hemorrhage from the axilla, nine days after deligation 
of the subclavian outside of the scaleni, which was ineffectual 
— twelve hours after its performance the patient died. 7 A 
ninth instance is mentioned by Chelius, which was operated 
upon by Arendt, where death, as in all the previous cases, 
closed the scene on the eighth day. 8 

1 Med. and Surg. Register, vol. i. 

2 Baltimore Med. and Surg. Journ., vol. i. 

3 Lecons Orales, torn. iv. p. 611. 

4 Fergusson's Surgery, p. 429, Philadelphia, 1845. 

5 Lancet, 1837. e Lancet, 1837. 

i Gazette Medicale, 1842. 8 System of Surgery, Trans, by South. 



284 CONTRIBUTIONS TO PRACTICAL SURGERY. 

The uniform want of success that has followed the applica- 
tion of a ligature to the arteria innominata, shows that the 
impetus of the blood has a great share in disturbing the pro- 
cess set up by nature after the ligature; to avoid this, Mr. 
Quain has proposed a modification of the operation, viz., the 
securing of the carotid and subclavian arteries, immediately 
as they arise from the innominata, it being supposed that by 
this means, the greater length of the artery from the arch of 
the aorta to the point of ligature would allow of a firmer 
coagulum to form. This modification was put in practice by 
Mr. Liston in 1838, in a case of subclavian aneurism, situated 
immediately beyond the scalenus muscle. On the eleventh 
day after the operation hemorrhage took place, and the pa- 
tient expired on the thirteenth day. On dissection, it was 
found that a clot had formed in the innominata, but none in 
the subclavian. 1 Another case in which both vessels were 
included in one ligature, just at their origin, occurred to M. 
Kuhl, of Leipsic, in 1836. The patient aged 43, was affected 
with a cancerous tumor in the neck, and the surgeon, at the 
time of the operation, believed that he had tied the carotid 
alone. Death followed on the third day. Upon dissection, 
the right carotid and subclavian arteries were found tied 
together at three lines above their origin from the innomi- 
nata, and their canals were in part obstructed. 2 

It may, perhaps, be well here to remark, that three cases 
are recorded, in which operations for securing the innominata 
have been actually begun and finally abandoned. Mr. Porter, 
in a case of aneurism, cut down upon this vessel, with a view 
of securing it, but finding it to be in such a condition as not 
to be advisable for a ligature, he prudently closed the wound. 3 

Dr. A. C. Post has given a somewhat similar case which 
occurred at the New York Hospital. The patient, aged 63, 
was affected with subclavian aneurism, and an explorative 
operation was performed "to determine the conditionof the 
subclavian and innominata, with the intention, if the arteries 
.should be healthy, to apply a ligature to the subclavian and 

1 Lancet, 1838. 2 Velpeau, Med. Operatoire, torn. ii. 

8 Fergusson's Surgery, p. 430. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 285 

carotid near their origin." The innominata, carotid, and sub- 
clavian were exposed, but the former was so much enlarged 
that it was deemed inexpedient to apply a ligature to it or to 
its branches, so that the wound was closed, and the patient 
sent back to his bed. This was done October 26, 1889, and 
he died exhausted by his sufferings, January 19, 1840. l The 
third case of this kind is that of Mr. Key, who commenced 
an operation upon a young woman affected with aneurism of 
the right subclavian, with the view either of passing a liga- 
ture around the innominata, or of tying both the subclavian 
and carotid near their common origin, as the state of the parts 
when disclosed by the knife might render most advisable. 
After exposing the arteria innominata, it was found impossi- 
ble to surround that vessel, in consequence of a tumor con- 
nected with it, and the operation, which had lasted one hour, 
was abandoned. The patient died, on the twenty-third day 
after it. 

Should the unfortunate results of all these cases prevent a 
resort to the operation of deligation of the brachio-cephalic 
trunk in future? We think but one answer can be returned 
to this query ; and are happy to find that the author of the 
most celebrated of our modern treatises on Operative Surgery, 
Velpeau, has already formally proscribed it. 



MORTALITY FOLLOWING THE OPERATION OF TYING THE 

FEMORAL ARTERY. 

The following tables show strikingly the dangers attendant 
upon the Hunterian operation, for what appears to be the 
most common form of external aneurism ; and, inasmuch as 
it is that to which the treatment by compression is more par- 
ticularly adapted, I have added to it a tabular statement of 
the cases treated by the latter method, taken from Mr. Belling- 
ham, together with such others as have come to my knowl- 
edge since the issue of his valuable little work from the 
press. 

1 New York Journal of Medicine, No. 4. 



286 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 



Surgeon Sex. 



J. Hunter M. 



J. Hunter M 

J. Hunter M 

J. Hunter M 

J. Hunter M 

Lynn M 

Birch M 



8 Cline 



9 
10 
11 

12 

13 

14 

15 
16 

17 

18 

19 



Kast M. 

Forster M. 



Earle 



M. 



Chopart | .. 

I 
Deschamps M. 

Deschamps M. 



Forster 
Deschamps 

Forster 
Home 



Pelletan 



20 Harris 



21 Scarpa 

22 [Home 



23 Home 

24 Knight 

25 .Home 

26 ; Pelletan 

27 I Scarpa 

28 Scarpa 

29 i Pelletan 



30 
31 



Pelletan 
A. Cooper 



32 A. Cooper 

I 

33 Scarpa 

34 Scarpa 



Age. Right or 
left side. 



45 

40 
35 
36 
42 
25 
43 

16 
35 










Left side 


Right side 







50 Left side 



34 

42 

37 
32 

37 
36 

60 
32 

33 

33 



33 
35 

50 

28 

46 

42 

70 



34 
27 
29 
34 



Left side 
Left side 
Left side 
Left side 



Disease or injury. 



Duration 
of disease. 

3 years 



Popliteal aneurism 



Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Femoral aneurism 
Popliteal aneurism 



Femoral aneurism from 3 days 

wound 
Popliteal aneurism 



Ligature 
separated. 



Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 



Leftside [Popliteal aneurism 

Right side Femoral aneurism 
Popliteal aneurism 



Popliteal aneurism 



Right side 'Popliteal aneurism 



Right side'Popliteal aneurism 
Right side Popliteal aneurism 



Left side 
Left side 

Right side 

Left side 



Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 

Popliteal aneurism 



Right side Popliteal aneurism 
Right side'Popliteal aneurism 



Right side 
Left side 



!Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Femoral aneurism 



Some on 
15th day 

14th day 
14th day 
29th day 
11th day 
13th day 



Removed 
9th day 



17th day 
15th day 



6 months 30th & 31st 
days 1 



14 months 



9 months 



15 days 



6 weeks 



46 .Right side Popliteal aneurism 



9 years 
6 months 



5 months 

4 months 

25 months 

5 months 



22d day 



10th day 
12th day 



11th day 
16 th day 



16th day 
30th day 



18th day 

18th day 
Removed 
25th & 26th 

days 
Removed 
on 22d day 
24th day 

14th & 15th 

days 1 
14th day 
21st day 



1 Double ligature. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



287 



Date of 
operation. 


Result. 


Period of 
death. 

26th day 


Cause of death. 


Work. 


December, 1785 


Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Died 

Died 

Cured 
Cured 
Cured 

Died 

Cured 

Died 

Cured 
Cured 

Cured 
Cured 

Died 

Cured 

Cured 
Cured 

Cured 
Cured 
Died 
Died 

Died 

Cured 
Died 

Cured 

Cured 

Cured 

Cured 
Cured 




by 

ich 

of 

ab- 

• 

of 

ar- 

lof 


Trans, of a. Soc. for Im- 




Hemorrhage 


provement of Med. and 

Chir. Knowledge, vol. i. 

do do vol. i. 




do do vol. i. 









do do vol. i. 








do do vol. i. 








do do vol. i. 


Nov. 3d, 1786 


11th day 


Hemorrhage 
Attacked 
fever, of wh 
he died 


do do vol. i. 
do do vol. i. 


May 28th, 1786 
Aug. 22d, 1791 
Jan. 28th, 1792 


Massachusetts Medical 






Comra.. 1790, vol. i. 
Medical Facts and Obser- 






vations, vol. V. 
Trans, of a Soc. for Im- 


March 28th, 1792 




Gangrene 
limb 


provement of Med. and 
Chir. Knowledge, vol. i. 
Obs. on Aneurism. Sy- 
denham Society, 1844. 
do do do 


April 7th, 1792 
June 19th, 1793 
June 24th, 1793 




In a few 

days 


Purulent 
sorption 


do do do 
Med. Facts & Obs., vol. v. 


Sept. 9th, 1793 
August 11th, 1794 






Obs. on Aneurism. Sy- 
denham Society, 1844. 
Med. Facts & Obs., vol. vi. 






1794 






Trans, of a Soc. for Im- 


April, 1795 
Nov 15th 1795 


7th day 


Gangrene 
limb 


provement of Med. and 

Chir. Knowledge, vol. ii. 

Clin. Chirurgicale, torn i. 

Trans, of a Soc. for Im- 


March 28th 1796 






provement of Med. and 

Chir. Knowledge, vol. ii. 

On Aneurism. Edin. 1808. 


June 9th, 1797 

July 14th, 1797 
Sept. 29th, 1797 
May 22d, 1798 
1798 

April 28th, 1799 

Feb 25th 1800 






Trans, of a Soc. for Im- 
provement of Med. and 
Chir. Knowledge, vol. ii. 
do do vol ii. 










do do vol. ii. 


12 th day 
5 months 

after 
37th day 


Hemorrhage 
Hectic & di 

rhoea 
Mortificatioi 

sac 


do do vol. ii. 
Clin. Chirurgicale, torn. i. 

On Aneurism. 

do do 


Feb. 1801 
Dec. 31st 1801 


43d day 


Hemorrhage 


Clin. Chirurgicale, torn. i. 
do do torn. i. 


April 13th, 1802 
May 3d, 1802 
March 3d 1803 






London Med. and Phys. 
Journ., vol. viii. 

do do vol. viii. 










On Aneurism. 


Feb 25th 1804 






do do 











238 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 


Surgeon. 


Sex. 
M. 


Age 
54 


Right or 
left side. 


Disease or injury. 


Duration 
of disease. 


Ligature 
separated. 


35 


Mursinna 




Popliteal aneurism 


7 months 






36 


Blizard 

Simpson 

At Deal 

Hospital 
Andrews 

Dawson 


M. 

M 


45 
?8 


Right side 
Right side 


Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 


6 months 
2 months 




37 




38 
39 
40 


M. 
M. 


54 


2 months 
2 months 
7 months 


12th & 14th 

days 1 
12th & 13th 

days 1 
23d day 


41 


Hosack 


M. 


30 


Right side 


Femoral aneurism 


2 months 


13th day 


42 

43 
44 
45 
46 

47 
48 


Dupuytren 

Hutchison 
Ramsden 
Ramsclen 
Ramsden 

Hutchison 

Kirby 

Hosack 


F. 

M. 
M. 
M. 
M. 

M. 
M. 
M. 


62 

48 
32 

34 

32 
33 


Right side 
Right side 
Left side 

Left side 
Right side 


Ruptured artery with 

fractured leg 
Femoral aneurism 
Femoral aneurism 
Popliteal aneurism 
Femoral aneurism 

Popliteal aneurism 
Popliteal aneurism 
Femoral aneurism from 


5 years 
9 months 
3 weeks 
15 weeks 

3 months 


15th day 

14th day 1 
14th day 
8th day 
14th & 15th 

days 
21st day 
15th day 
13th day 


49 


2 months 


50 


Onderdonk 


M. 


40 




wound 
Popliteal aneurism 


1 month 


22d & 23d 


51 


Onderdonk 
Mackesy 

Lawrence 


1YT 


38 


Right side 


Wounded knee joint 
Femoral aneurism 




days 1 
18th day 1 


52 


1 year 
1 year 


53 


M. 




Popliteal aneurism 


18th day 


54 


Dickinson 
Dease 


M." 


26 


Right side 


Popliteal aneurism 
Popliteal aneurism 






55 


6 months 


In 24 hours 


56 
57 


Travers 
Crampton 


M. 


39 




Aneurism of posterior 

tibial 
Popliteal aneurism 


4 weeks 


removed 
5th day 

On 3d day 


58 
59 


Browne 
Browne 


M. 
M. 


25 

27 




Popliteal aneurism from 
wound from necrosed 
femur 

Aneurism of posterior 
tibial 


8 days 
2 months 


removed 


9th & 11th 
days' 


60 
61 


Norman 

Norman 

Kirby 

Norman 

Physick 


M. 
M. 

M. 
M. 
M. 


36 
37 
23 
38 


Right side 
Left side 
Left side 
Right side 


Popliteal aneurism 
Popliteal aneurism 
Femoral aneurism 
Popliteal aneurism 
Varicose aneurism be- 
low the knee 


1 week 

2 weeks 

3 days 
12 years 


15th day 


62 
63 


21st day 


64 








65 


Roberts 

! 

Dupuytren 
Monteath 


M. 
M. 
M. 


32 




Popliteal aneurism 

Diffused aneurism upper 
part of leg from gunshot 
Popliteal aneurism 




In 24 hours 


66 
67 


1 month 


removed 
20th day 

30th day 







1 Double ligature. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



289 



Date of 
operation. 


Result. 


Period of 
death. 

33d day 


Cause of death. 


Work. 


April 1st, 1804 
July 24th, 1804 
Nov. 23d, 1804 


Died 

Died after 

amputation 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 
Cured 
Cured 

Cured 
Cured 
Cured 

Cured 

Cured 
Cured 

Cured 

Died 
Cured 

Died 

Cured 

Died 

Died 

Cured 
Cured 
Cured 
Cured 
Died 

Cured 
Cured 
Cured 


Gangrene of 

limb 
Gangrene of 

limb 


On Anuerism. 
do do 




London Med. and Phys. 
Journ., vol. ii., N. S. 
do do vol xvii. 

do do vol. xvii. 


March 18th, 1805 
Oct. 19th, 1805 


27th day 


Hemorrhage 


May 11th, 1807 
March 31st, 1808 






Edinburgh Med. & Surg. 

Journ., vol. iii. 
Amer. Med. & Phil. Reg., 

vol. iii. 
Lecons Orales, torn. iv. 

Case3, p. 9. 

Practical Observations. 






Jan. 3d, 1809 






July 5th, 1810 
Sept. 24th, 1810 














do do do 








do do do 


Feb. 19th, 1811 




Feb. 8th, 1S13 






do 


March 1st, 1813 






Amer. Med. & Phil. Reg., 
vol. iii. 

do do vol. iv. 


May 15th, 1813 
June 17th, 1813 










do do vol. iv. 


Oct. 8th, 1813 






Edinburgh Med. & Surg. 

Journ., vol. xi. 
Med. Chirurg. Transacts., 

vol. vi. 
Lond. Med. Repos., vol. i. 
Med Chir Trans., vol. vii. 


October, 1813 








23d day 


Tetanus 


Feb. 27th, 1815 


Feb. 23d, 1816 
October 14th 


7th day 


Hemorrhage 


do do vol. vii. 


Sept. 1st, 1817 
Sept. 1st, 1817 

Oct. 6th, 1817 




Gangrene of 
limb 

Thoracic in- 
flammation and 
abscess in the 
course of the 
artery 




41st day 


Medico-Chirurgical Rev., 
vol. xxiv. 


June 6th, 1818 








Feb. 20th, 1818 








March 7th, 1818 






Med Chir. Trans., vol. x. 








Dorsey's Elements, vol. ii. 
Med. Chir. Trans., vol. xi. 


June 6th, 1818 




limb and he- 
morrhage 


1818 






Lecons Orales, torn. iv. 

Cooper's Surg. Dictionary, 

1838 


Feb. 27th, 1819 













290 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 

68 

69 
70 

71 
72 
73 

74 

75 

76 

77 

78 

79 

80 
81 

82 

83 

84 

85 

86 

87 
88 

89 

90 

91 

92 

93 

94 

95 

96 



97 

98 

99 

100 
101 
102 



Surgeon. Sex 



Dupuytren 

Janson 
Adam 

Liston 
Liston 
Carmiehael 

At Meath 

Ilospital 
Todd 

Todd 
Perry 

Gunning 

Travers 

Travers 
Travers 
Liston 

A. Cooper 

Travers 

Liston 



D. L. 

Rogers 
Stephenson F. 
Mott |M 



Key 

Uecelli 

Travers 

Benja 

Arnott 

Dupuytren M 

C. Bell M 



Baynham 



M. 



McFarlane M. 
McFarlane^. 

McFarlane M. 

McFarlane M. 
Wright |M. 
McFarlane M. 



Age. Right or 
I left side. 



39 Right side 

49 ! 

30 i Left side 

35 Right side 

30 Left side 

40 Right side 



Disease or injury. 



30 

27 
45 

47 

25 

25 
31 
35 

47 

32 

43 

30 

90 
34 

30 



37 
50 
34 
22 
45 
20 



45 
45 

36 

42 
38 
38 



Right side 

Left side 
Right side 



Left side 
Right side 

Left side 



Left side 
Left side 

Left side 
Left side 

Left side 



Left side 
Right side 

Left side 

Left side 
Right side 
Right side 



Pulsating tumor of head 

of tibia 
Popliteal aneurism 
Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 
Femoral aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 
Femoral aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 

Wound of knee-joint 

Popliteal aneurism 
Compound dislocation of 

ankle 
Popliteal aneurism 

Popliteal aneurism 

Femoro -popliteal aneu- 
rism 
Popliteal aneurism 



Duration Ligature 
of disease.; separated. 



|15th day 



11th day 

2 months ^thA 21st 

days 1 

3 weeks '22d day 
12monthsl7th day 



4 months 

2 months 
1 month 



18th & 19th 

days 1 
18 ch day 



6 weeks |17th day 

7 weeks 19th day 

13th day 

2 weeks 18th day 



2 months 



42d day 



15th day 1 
2 months 18th day 



Popliteal aneurism 

Varicose aneurism 

thigh 
Popliteal aneurism 



of 



6 weeks 



6 months 24th day 1 
4 months ;31st day 
6 months 



Varicose aneurism of 
thigh and aneurismal 
varix near the ankle 
Popliteal aneurism 
Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 
Aneurism of anterior 
tibial and popliteal 



4 years 
3 years 



11th day 



7 months 12th day 



3 weeks 19th day 

5 weeks j26th day 
1 year 45th day 



1 Double ligature. 



MORTALITY FOLLOWING LIGATURE OP ARTERIES. 



291 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


March 16th, 1819 


Cured 

Cured 
Cured 

Cured 
Cured 
Died 

Died 

Cured 

Cured 
Cured 

Cured 

Cured 

Cured 
Cured 
Cured 

Died 

Died 

Cured after 

amputation 

Cured 

Cured 
Died 

Died 

Died 

Died 

Cured 

Died 

Died 

Died 

Cured 

Cured 
Died 

Died after 

amputation 

Cured 

Cured 

Cured 




of 
of 

of 

of 

an- 

>rta 

of 

of 
of 


Repertoire d'Anat., torn. ii. 

Melanges de Chirurgie. 
Edinburgh Med. & Surg. 
Journ., vol. xviii. 


July, 1818 
April 3d, 1819 

Oct. 1st, 1819 














Oct. 5th, 1819 






do do vol. xvi 


May 25th, 1818 

1819 

Sept. 1st, 1820 

Sept. 1st, 1820 
Jan. 20th, 1821 


19th flay 


Phlebitis 
Hemorrhage 


Transacts. Coll. of Phys. 
of Ireland, vol. ii. 
do do vol. ii. 

Dub. Hosp. Reps., vol. iii. 










Glasgow Medical Journal, 
vol. iv. 


April 27th, 1821 
Nov. 22d, 1822 










ries, 1830. 
London Med. and Phys. 
Journ., vol. iii., N. S. 
do do vol. iii., N. S. 


April 11th, 1823 
Feb. 24th, 1823 










do do vol. ii., N. S. 


April 2d, 1823 
May 30th, 1823 




Edinburgh Med. & Surg. 

Journ., vol. xxvii 
Lectures by Tyrrell. 

London Med. and Phys. 

Journ.. vol. iii., N. S. 
Edinburgh Med. & Surg. 

Journ., vol. xxvii. 
N. Y. Med. and Physical 

Journ., vol. iii. 
Lancet, vol. ii., 1827-28. 


28th of 
July 
4th day 


Gangrene 

limb 
Gangrene 

limb 


Jan. 25th, 1824 


Aug. 4th, 1824 
Aug. 18th, 1824 








Sept. 2d, 1824 
Oct. 4th, 1824 


7th day 
11th day 
26th day 
3d day 


Tetanus 

Gangrene 

limb 
Diarrhoea 

Gangrene 
limb 


N. Y. Med. and Physical 

Journ., vol. iii. 
Lancet, October, 1824. 

Archives Generales, vol. 


Jan. 21st, 1825 
Aug. 21st, 1825 
Oct. 28th, 1825 
May 17th, 1826 
Feb. 20th, 1826 


v., 1824. 
Lancet, January, 1825. 

London Med. and Phys. 
Journ., vol. Iv. 

do do vol lv. 

Meras. de l'Acad. Roy. de 

Med., torn. iii. 
London Med. and Phys. 

Jour.,vol.i.,N. S.,1826. 
Midland Medical & Surg. 


12 weeks 

after 
8 th day 

7th day 


Bursting of 
eurism of ac 
Gangrene 
limb 


March 10th, 1826 




March 29th, 1826 






Journ., vol. iii. 

Surgical Reports, 1832. 
Surgical Reports. 

do do 

do do 


May 14th, 1826 

June 2d, 1826 

July 9th, 1826 
July 26th, 1826 
Nov. 15th, 1826 




Gangrene 

limb 
Gangrene 

limb 


Aug. 12th 






Med. Repos., vol.vi., 1828. 
Surgical Reports. 













292 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 



Surgeon. 



Ehrmann 
Lalletnand 

Dickinson 

Lisfranc 

Carlisle 

Dupuytren 

Dupuytren 

Briggs 

Pierpont 



303 
104 

105 

106 

107 
108 
109 
110 
111 

112 Guthrie 

113 jGuthrie 

114 S. Cooper 



Sex, 



115 

116 

117 



Collis 

Tyrrell 

Mayo 



118 ;Moulinie 

119 [Syme 



M. 
M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 
M. 
M. 



M. 

F. 

M. 

M. 



120 



McFarlane M. 



Green 

Collis 
Morrison 



M. 

M. 
M. 



121 

122 
123 

124 

125 

126 'Collis IM. 

127 B. Cooper M, 



128 
129 
130 
131 



Breschet M. 
N.R.Smith M. 
N.R.Smith M. 



Travers 



132 I Barry 

133 Hay ward 

134 | Key 

135 Key 

136 Perry 



M. 

M. 

M. 

M. 

M. 

M. 



137 JAtMeath M. 
Hospital 



Age, 



43 
45 



23 

46 
35 

30 

30 

26 
33 

48 



58 
54 

49 
25 

42 



38 

30 

37 



Disease or injury. 



Right or 
left side. 

Right side 
Right side 

Right side 
Right side 
Right side 

Left side Popliteal aneurism 
Leftside Popliteal aneurism 
Left side Popliteal aneurism 



Popliteal aneurism 
Pulsating tumor of head 

of tibia 
Wounded femoral 

Wounded femoral 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 

Femoral aneurism 



Right side 
Left side 



Popliteal aneurism 

Popliteal aneurism 
Femoral aneurism 

Femoral aneurism 
Popliteal aneurism 



Morrison M. [ 26 

Collis jM. I 38 

38 

41 



32 

30 

31 

45 

44 
28 

36 

26 

47 



Secondary hemorrhage 
after amputation of 
leg 
Right side ! Aneurism of posterior 

tibial 
Left side Popliteal aneurism 
iRight side Femoral aneurism 

Right side Popliteal aneurism 
Right side Popliteal aneurism 
Left side Popliteal aneurism 

iComp. fracture femur 

with rupture of femo- 
ral artery 
Right side Popliteal aneurism 

Left side Popliteal aneurism 

Right side Femoral aneurism 

Popliteal aneurism ' 



Duration 
of disease, 

9 months 



Popliteal aneurism 
Popliteal aneurism 



Right side Popliteal aneurism 
Left side 'Popliteal aneurism 



Left side 



Varicose aneurism of 

femoral 
Popliteal aneurism 



2 months 



4 months 



5 weeks 

2 months 

6 weeks 
5 years 



6 weeks 
2 months 

2 years 

3 weeks 



1 year 

2 months 



15 years 
15 years 



6 months 



2 years 

3 weeks 

3 months 

5 weeks 

4 years 



Ligature 
separated. 



22d day 
36th day 

17th & 24th 

days 1 
10th & 11th 

days 1 



17th day 
2 lit day 



17th day 
31st day 



17th day 

58th day 
22d day 

29th day 
16th day 
39th day 



I 7th day 

17th day 
17th day 
27th day 
16th day 



19th day 



60th day 
16th day 

46th day 

2Sth day 



1 Double ligature. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



293 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


May 11th. 1827 
April 4th 

March 25th, 1828 


Cured 
Cured 

Cured 

Cured 

Died 

Died 

Died 

Cured 

Cured after 

amputation 

Cured 

Cured 

Cured after 

amputation 

Cured 

Cured 
Cured 

Cured 
Cured 

Cured 

Cured 

Cured 
Cured 

Cured 
Cured 
Cured 
Cured 

Died 

Cured 

Cured 

Cured after 
amputation 
Cured 
Cured 

Cured 

Cured 
Died 

Died 




Repert. d'Anat., torn. v. 
do do torn. ii. 








Amer. Journ. Med. Sci., 


June 3d, 1828 






vol. iv., 1829. 
Amer. Journ. Med. Sci., 


Aug. 9th, 1828 
Feb. 20th, 1828 
Feb. 16th, 1829 
March 6th, 1829 


Begin'ing 
of Sept. 
27th day 

26 th day 


Gangrene of 

limb 
Gangrene of 

limb 
Dry gangrene 

of limb 


vol. iv., 1829. 
Lancet, vol. i., 1828-29. 

Lancet, vol. ii., 1828-29. 

Med. Chirurg. Review, vol. 

xi., N. S., 1829. 
Guthrie's Diseases of Arte- 


Oct. 4th, 1829 






ries, 1830. 
Midland Med. and Sure. 


April 10th, 1830 
May 15th, 1830 
April, 1830 

Jan 22d, 1831 






Journ , vol. ii. 
Med. Chir. Rev., vol. xiii. 






do do vol xiii. 






Med. Chir. Trans., vol. xvi. 






Cyclop, of Anat. & Pys., 

vol i. p. 236. 
Med. Chir. Rev., vol., xvi. 


Feb. 25th, 1831 






May 20th, 1831 

Aug. 23d, 1831 
Aug. 30th, 1831 

Dec. 19th, 1831 






London Med. and Phys. 

Journ., vol. xi., 1831. 
Journal Hebdornadaire. 










Edin. Monthly Journal, 

vol. for 1842. 
Surgical Reports, p. 279. 

South's Trans, of Chelius, 






Sept. 21st, 1832 
Nor. 12th, 1832 










vol. ii. 
Dub. Med. Journ., vol. v. 


Dec. 13th, 1832 






Amer. Journ. Med. Sci., 


Jan. 30th, 1833 






vol. xix. 

do do vol. xix. 


Nov. 10th, 1833 






Dub. Med. Journ., vol. v. 


Dec. 14th, 1833 






do do vol. v. 


February 9th 

February 18th 
August, 1834 
March 4th, 1835 






Surgical cases. 

Mems. de l'Acad. Roy. de 

Med., torn. iii. 
Baltimore Med. & Surg. 

Journ., vol. ii. 
N. A. Archives of Med. & 


28th day 


Gangrene of 
limb 






Sept. 5th, 1834 
March 27th, 1834 






Surg., vol. ii. 
On Constitutional Irrita- 






tion, 1835. 
Lancet, vol. i., 1834-35. 


Dec. 27th, 1834 






Boston Medical and Surg. 


May 26th, 1835 
Oct. 6th, 1835 






Journ., vol. xxi., 1835. 
Guy's Hospital Reports, 
vol. i. 

do do vol. i. 


6th day 
16th day 




Sept. 10th, 1835 


Hemorrhage 
Phlebitis 


Med. Chir. Trans., vol. xx. 

Porter in Cyclop, of Anat., 
vol. i 





294 



CONTRIBUTIONS TO PRACTICAL SURGERY. 






No. 


Surgeon. 


Sex. 


Age 


Right or 
left side. 

Left side 


Disease or injury. 


Duration 
ofdisease. 


Ligature 
separated. 


13S 


Engle- 
hardt 


M. 

M 


19 
33 


Supposed popliteal aneu- 
rism 
Popliteal aneurism 

Popliteal aneurism 


3 weeks 




139 


17th day 
19th day 


140 


Syme 


M. 


39 


Left side 


4 months 


141 


Klingsolir 


M. 


39 




Femoral aneurism 




14th day 


142 
143 


B. Cooper 
S3' me 


M. 

M. 


28 
51 


Right side 


Popliteal aneurism 
Popliteal aneurism 


2 weeks 

3 months 


11th day 
19th day 


144 


Busk 
Turner 

Bougard 

Morrison 


M. 

M. 

M. 


37 

35 

42 


Left side 
Right side 


Popliteal aneurism 
Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 


5 weeks 




145 




146 


5 months 
12 months 




147 


29th day 


148 


Harris 


M. 


30 


Left side 


Varicose aneurism of 
femoral 


15 months 


Removed 
on 22d day 


149 


Auchinloss 


M. 




Left side 


Popliteal aneurism 


2 months 


16th day 


150 


Blandin 


M. 


29 


Right side 


Popliteal aneurism 




19th day 


151 
152 


Norris 
Phillips 


M. 
M. 


32 
46 


Left side 
Left side 


Pulsation tumor of head 

of tibia 
Popliteal aneurism 


6 months 
20 days 


17th day 
19th day 


153 


Shipman 


M. 


30 




Popliteal aneurism 


2 months 


20th day 


154 


Lawrie 


F 


23 


Left side 


Popliteal aneurism 


5 months 


15th day 


155 


Lenoir 


M. 


37 


Right side 


Popliteal aneurism 




17th day 


156 


Lenoir 
Bullock 


M. 
M. 


49 
41 


Left side 


Popliteal aneurism 
Popliteal aneurism 


6 months 
6 months 




157 


24th day 


158 


Syme 


M. 


26 


Left side 


Popliteal aneurism 


3 months 


25th day 


159 


Lawrie 


M. 


22 


Left side 


Popliteal aneurism 


2 years 


15th day 


160 


Syme 


M 


?9 


Right side 

Right side 
Left side 
Left side 
Right side 


Popliteal aneurism 

Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 


1 month 




161 


M. 
M. 
M. 
M. 
M. 


33 
55 
28 
31 






162 
163 
164 


B. Cooper 
B. Cooper 
B. Cooper 
Lawrie 


5 weeks 
18 weeks 
3 months 
2 months 


23d day 
23d day 


165 


15th day 


166 


Syme 


M. 


33 


Right side 


Popliteal aneurism 


1 month 


38th day 


167 


Grutteriez 
Gutteriez 
Syme 


M. 
M. 
M. 


25 
25 
17 


Left side 
Right side 
Left side 


Femoral aneurism 
Popliteal aneurism 
Femoral aneurism from 




18th day 
23d day 
18th day 


168 




169 


3 months 


170 
171 

172 
173 
174 


Lizars 
Syme 

Teale 
Quain 
Syme 


M. 
M. 

M. 
M. 
M. 


46 
62 

30 
50 
25 


Left side 

Right side 
Left side 
Left side 


wound 
Popliteal aneurism 
Hemorrhage after frac- 
tured leg 
Popliteal aneurism 
Popliteal aneurism 
Popliteal aneurism 


5 months 

1 month 
18 months 
3 weeks 


35th day 
38th day 

17th day 
31st day 
37th day 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



295 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 




Died 

Cured 

Cured 

Cured 

Cured 
Cured 

Cured 

Died after 
amputation 
Cured 
Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 
Cured 

Cured 

Cured 

Cured 

Died 

Cured 

Cured 

Cured 

Cured 

Cured 

Cured 
Cured 
Cured 

Cured 
Cured 

Cured 
Cured 
Cured 






Gazette Medicale, 1835. 


Mar. 23d, 1836 






Amer. Journ of Med. Sci 


May 9th, 1836 

July 15th 

July 20th, 1836 
July 22d, 1836 

July 24th, 1836 






vol. xix. 
Edin. Med. & Sur°- 






Journ., vol. xlvi. 
Archives Generales, torn. 






xliv. 
Guy's Hosp. Rep's, vol. i. 
Edin. Med. & Sur«\ 








o 

Journ., vol. xlvi. 
Lond. Med. Gaz., vol. xix 




Gangrene 


Edin. Med. & Surg. 

Journ , vol. xlvi. 
Gaz. Med., No. 15, 1844 


1836 




Jan. 15th, 1837 






Amer. Journ. of Med. Sci 


July 11th, 1837 
Oct. 8th, 1837 


1 month 
after 


Gangrene of 
limb and 
hemorrhage 


vol. xxii. 
Amer. Journ. of Med. Sci., 
vol. i., N. S., 1841. 

Lond. Med. Gazette, vol 


May 24th, 1838 
Sept, 22d, 1838 






i., 1842-43. 
Gazette des HOpitaux, No. 

98, 1838. 
Amer. Journ. of Med Sci 










vol. XXV. 
Lond. Med. Gazette vol 


June 18th, 1839 






i., 1838-39. 
Boston Med. & Surg. 

Journ., vol. xxiv. 
Lond. Med. Gazette, vol 


Sept. 22d, 1839 
Oct. 3d, 1839 










i., 1842-43 
Archives Generales, tom 


1839 






i., 4e serie. 

do do tom. i., 4e serie 


Oct. 30th, 1839 






Lond. Med. Gazette, vol 


Dec. 3d, 1839 






ii., 1840. 
Lond. and Edin. Monthly 

Journ., vol. i. 
Lond. Med. Gazette, vol 


April 1st, 1840 

April 30th, 1840 

July 4th, 1840 
Sept. 8th, 1840 
Oct. 6th, 1840 










i., 1842-43. 
Lond. and Edin. Monthly 

Journ., vol. i. 
Porter on Aneurism. 
Guy's Hosp. Rep's, vol. vi. 

do do do vol vi 


15th day 


Phlebitis 






Dec. 26th, 1840 






do do do vol. vi 


Nov. 24th, 1840 






Lond. Med. Gazette, vol 


Feb. 17th, 1841 






i., 1842-43. 
Lond. and Edin. Monthly 

Journ., vol. ii. 
Annales de Chir., tom. iv. 


Mar. 4th, 1841 






Mar. 26th, 1841 






do do do tom. iv. 


May 26th, 1841 

May 28th, 1841 
June 2d, 1841 






Lond. and Edin. Monthly 
Journ., vol. ii., 1842. 
do do do vol. i., 1841. 








Edin. Monthly Journ., vol. 

for 1842. 
Lond. Med. Gazette. 


Aug. 4th, 1841 
Aug. 12th, 1841 








Lancet, vol. i., 1841-42. 


Aug. 30th, 1841 






Lond. and Edin. Monthly 
Journ., vol ii., 1842. 




1 



296 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



No. 

175 
176 
177 
178 

179 

180 

181 

182 

183 

184 

185 

186 

187 

188 

189 
190 
191 

192 
193 

194 

195 

196 
197 

198 

199 

200 
201 
202 

203 

204 



Surgeon. 



Laugier 
Quain 
Adams 
Mackenzie 

Syme 

Fox 

Phillips 

Lawrie 

Lawrie 

Harrison 

Syme 

Notting- 
ham 
Nelaton 



Syme 

Syme 
Hancock 
A. E. Ho 

sack 
Norris 
Cheesman 



Syme 

Toogood 

Sabine 
C. B. Gib 

son 
Judd 

B. Cooper 
Roux 
Bird 
Bird 

Roux 

Wright 



Sex. 



M. 
M. 
M. 
M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 
M. 
M. 

M. 
M. 

M. 

M. 

P. 
M. 

M. 

M. 
M. 
M. 
M. 

M. 

M. 



Age, 



50 
35 

28 
18 

42 

12 

53 

31 

30 

42 

9 

43 



32 

32 

55 

35 
25 

42 

36 

40 
45 

32 

30 

58 
38 
38 

45 

37 



Right or 
left side. 



Left side 

Right side 

Right side 
Right side 
Right side 
Right side" 

Right side 

Left side 

Right side 
Left side 

Left side 
Right side 



Right side 
Right side 

Right side 

Left side 
Right side 
Right side 
Left side 

Left side 



Disease or injury. 



Duration 
of disease. 



Popliteal aneurism 3 weeks 

Popliteal aneurism 5 weeks 
Popliteal aneurism 
Hemorrhage 

Popliteal aneurism 6 weeks 

Aneurism of anterior Some 

tibial from wound weeks 

Popliteal aneurism 3 weeks 

Popliteal aneurism 10 months 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 2 years 

Popliteal aneurism 7 months 

Pulsating tumor of 

intern, condyle of 

femur 

Popliteal aneurism 5 months 

Popliteal aneurism 

Popliteal aneurism 10 weeks 

Popliteal aneurism 

Popliteal aneurism 6 months 

Wounded anter. tibial 

and interosseal arte- 
ries 

Popliteal aneurism 2 months 

Popliteal aneurism 1 year 

Popliteal aneurism 

Femoral aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 

Popliteal aneurism 2 years 

Popliteal aneurism "A few 

weeks" 

Popliteal aneurism 7 months 

Popliteal aneurism 6 days 



Ligature 
separated. 



18th day 
17th day 
10th day 



25th day 
21st day 
9th day 



10th day 
20th day 
14th day 
24th day 



21st day 



15th day 
26th day 

26th day 



36th day 
11th day 



18th day 



22d day 

13th day 
7 weeks 



26th day 



MORTALITY" FOLLOWING LIGATURE OF ARTERIES. 



297 



Date of 
operation. 


Result. 


Period of 
death. 


Cause of death. 


Work. 


Sept. 23d, 1841 
Oct. 17th, 1841 


Cured 
Cured 
Died 
Died 

Cured 

Cured 

Died 

Cured after 
amputation 

Died after 
amputation 

Cured 

Cured 
Cured 
Cured 

Cured 

Cured 
Cured 
Cured 

Cured 
Died 

Cured 

Cured after 
amputation 
Died 
Cured 

Died 

Cured 
Died 
Cured 
Cured 

Died after 
amputation 
Cured 












1841 
Mar. 31st, 1842 


In 24* 

hours 


Gangrene 


Dub. Med. Journ., vol. xix. 
Liston on a Variety of 

False Aneurism, 184,2. 
Lond. and Edin. Monthly 

Journ., vol. ii., 1842. 
Amer. Journ. of Med. Sci., 

vol. v., N. S., 1843. 
Lond. Med. Gazette, vol., 

i., 1842. 

do do do vol. i., 1843. 

do do do vol. i., 1843. 
do do do Oct. 1845. 

Lond. and Edin. Monthly 

Journ. for 1844. 
Guy's Hosp. Reports, Oct. 

1845. 
Lancet, vol. i., 1845. 

Monthly Journ. of Med. 

Sci., 1846. 

do do do 1846. 
Lancet, vol. ii., 1845. 
N. Y. Journ. of Med. & Coll. 

Sci., vol. i., N. S., 1848. 
At Pennsylvania Hospital. 
Annalist, vol. i., 1846. 

Month. Journ. of Med. 
Sci., 1846-47. 
do do do 1846-47. 

Annalist, vol. i. 

Amer. Journ. of Med. Sci., 

vol. xiv., N. S., 1847. 
Lond. Med. Gazette, vol. 

v., 1847. 
Guy's Hosp. Rep's, vol. ii. 
L'Experience, torn. vi. 
Lancet, vol. i., 1837-38. 

do vol. i., 1837-38. 

These of Figuiere, 1845. 


July 19th, 1842 
Sept. 17th, 1842 
1842 
July 13th 








43d day 


Gangrene of 
limb 




Gangrene of 
limb 


Nov 1st 1843 




Feb 24th 1844 






Oct 14th 1844 






Mar 10th 1845 






Sept. 17th, 1845 
Nov 26th 1845 










Sept. 6, 1845 
March 1846 










April 22d, 1846 
July 7th, 1S46 

Oct. 2d 1846 






25th day 


Phlebitis 


Mar. 1st, 1847 






Mar 15th 1847 


9th day 




July, 1847 
Nov. 1st, 1847 
Mar. 18th, 1837 




14th day 


Tetanus 


July 31st, 1840 
Jan. 7th, 1837 


19th day 


Phlebitis 


Mar. 7th, 1837 






June 13th, 1835 
1848 




Gangrene 











20 



298 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



Mortality. — The foregoing table contains a list of two hun- 
dred and four cases in which the femoral artery has been 
ligatured by the Hunterian method. Of these, one hundred 
and fifty-four recovered, and fifty died. Six of the patients 
who recovered undergoing amputation in consequence of gan- 
grene of the limbs. 

Disease or injury. — Of the whole number of cases contained 
in the tables, the artery was tied in one hundred and fifty-five, 
for the cure of popliteal aneurisms; in twenty-two, for femoral 
aneurisms; in six, for aneurismal tumors of the leg; in four, 
for pulsating tumors of the head of the tibia or condyle of the 
femur; in five, for varicose aneurisms; in three, for rupture 
of the artery, accompanying fractures of the leg or thigh; in 
eight, in order either to prevent or abate inflammation after 
wounds or dislocations, or to arrest hemorrhage, either pri- 
mary or secondary ; and in one, for a supposed popliteal 
aneurism. 

Of the one hundred and eighty-eight cases in which the 
operation was done for the cure of aneurisms, one hundred and 
forty -two were cured, and forty-six died. 

Sex. — Of one hundred and eighty -three cases of aneurisms, 
in which this is noted, one hundred and seventy-seven occurred 
in males, and six in females. 

Right or left side. — Of one hundred and twenty-four cases 
of aneurisms where the side is mentioned, sixty -three were on 
the right and sixty-one on the left side. 

Age. — The age is noted in one hundred and sixty-four cases 
of aneurisms, and of these there were: — 



Under 10 years 


1 a true aneurism 


Between 10 and 20 . 


. 4 " 


" 20 and 30 . 


. 30 " 


" 30 and 40 . 


. 72 « " 


" 40 and 50 . 


. 40 " " 


" 50 and 60 . 


. 14 " 


60, and above, . 


. 3 1 " " 




Total 164 



1 One of these was a female, aged ninety, who is stated to have been 
living and well three years after the operation was performed. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 299 

Period the ligature separated. — In one hundred and thirty- 
cases 1 in which the ligature separated spontaneously, it came 
away in ninety-one before the twentieth day ; in thirty-seven, 
between the twentieth and thirtieth days; in fourteen, between 
the thirtieth and fortieth days; and in five, beyond the fortieth 
day. The longest period to which it remained was the sixtieth 
day, and the shortest the fifth day. 

Return of pulsation in the aneurismal tumor after the appli- 
cation of the ligature. — This was observed in nineteen cases. 
In No. 23, a slight pulsation in the sac was observed on the 
day following the operation, on the next day it was more dis- 
tinct, but two days afterwards it became much less. The 
patient recovered. In No. 25, some pulsation was observed 
in the tumor on the fourth day after the operation, and the 
patient died on the twelfth day of hemorrhage. In the third 
case, No. 60, pulsation appeared in the tumor on the day after 
the operation, but ceased on the sixteenth day, the patient 
recovering. In No. 67, nine months after recovery from the 
operation, the tumor, which had diminished so much as to 
have become barely perceptible, and was without pulsation, 
reappeared, and pulsation in it became distinct. The cure 
was finally completed by compression. In the fifth case, No. 
78, the artery was ligatured April 27th, 1821. On the 20th of 
July, 1825, he was readmitted, and stated that the tumor had 
entirely disappeared soon after he was discharged in 1821, but 
that, five or six weeks before his readmission, he observed 
that its swelling had returned at the upper part of the ham, 
and was at that time nearly of the size of a hen's egg. It was 
proposed to take up the artery between the part tied in the 
former operation and the aneurismal sac; but, as the first 
operation had not succeeded, the patient preferred amputation. 
He died eight hours after it. The femoral was found to be 
obliterated, for the space of half an inch, at the part where 
the ligature had been applied four years before. Immediately 
below it, two small branches were observed to enter the con- 
tinued trunk of that vessel. These were equal to half the 



1 In some of the cases a double ligature was used. 



300 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



diameter of the femoral vessel. The anastomosing branches 
given off above the obliterated portion were a good deal 
enlarged. In No. 82, the disease was a femoral aneurism, and 
the artery was tied in April, 1823. On the 25th of January 
following, he had a return of pulsation in the tumor, which 
disappeared under the application of cold and compression. 
In No. 95, all pulsation in the tumor ceased upon tightening 
the ligature, but returned in a few minutes. In half an hour 
after the operation it was nearly as distinct as before the 
artery was tied, but on the third day the pulsation ceased. 
The patient died ; and on dissection, the femoral artery, just 
below the part where the profunda was given off, was found 
to be divided into two nearly equal branches. These ran 
down parallel to each other, to the part where the artery 
passes through the tendon of the triceps muscle, when they 
again united. The ligature had been placed on the most 
superficial vessel. 1 In the eighth case, No. 96, which was one 
of varicose aneurism at the middle of the thigh, with an 
aneurismal varix near the ankle, pulsation was observed in 
the varix at the ankle on the fourth day; the patient recov- 
ered, but was not cured. In the year after the operation, the 
tumor was stationary with the same pulsation. In No. 102, 
aneurismal tumors existed in both the anterior tibial and 
popliteal arteries : pulsation returned in both on the twelfth 
day, but ceased four days afterwards, and the patient was 
cured. In No. 110, the operation was done in March, 1829 ; 
pulsation ceased after it, and the tumor diminished in size. 
He returned to work, and it ultimately entirely disappeared. 
In the month of September following, the tumor reappeared 
with pulsation. By the application of a hard compress on the 
inner part of the thigh, which he wore for two months, night 
and day, the pulsation ceased, and one year after the opera- 
tion no appearance of swelling was to be perceived. In No. 
134, pulsation in the sac returned the day after the operation, 
but rapidly disappeared. In No. 136, the disease was a vari- 



' I have seen it stated that preparations, showing a similar distribution, 
exist in the Royal College of Surgeons at Dublin, and in St. Bartholomew's 
Hospital at London. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 301 

cose aneurism of the femoral. Four hours after the operation, 
feeble pulsation was noticed in the tumor, and on the following 
day it became stronger. The patient died. In No. 144, the 
operation was done on the 24th of July; on the 31st, indis- 
tinct pulsation was observed in the tumor. By the 7th of 
August it had increased, and is afterwards noticed as present 
on the 15th and 25th. By the 4th of September it was free 
from all pulsation. In the fourteenth case, No. 155, pulsation 
was noticed in the tumor five months after the operation, 
though it was small and hard ; the sac afterwards suppurated, 
and the case did well. In No. 161, pulsation reappeared in 
the sac on the tenth day, and gradually increased in violence 
until the man began to sink. In No. 190, pulsation was noticed 
in the tumor on the eighth day, and on the twentieth day was 
no longer perceptible. In the seventeenth case, No. 191, 
where the operation was performed in March, the pulsation 
and size of the tumor had returned to nearly its original size 
and force by the middle of August. Compression on the 
artery was employed, and at the end of five days removed. 
After a fortnight, a slight thrill being again detected in it, it 
was reapplied for thirty-six hours, and a perfect cure effected. 
In No, 199, the patient had been operated upon, on the same 
side, six months previously, by M. Greaves, of Manchester. 
Pulsation returned in the sac twelve hours after it, and the 
disease was not cured. Upon close examination in the course 
of the cicatrix, the pulsation of the vessel was discovered, 
though certainly not of a natural sized artery, nor did any 
degree of pressure upon this command the pulsations of the 
aneurismal tumor. In the lower third of the thigh the pulsa- 
tion of the artery was very perceptible, and pressure here 
immediately stopped the flow of blood into the tumor. Mr. 
Cooper believed that the cause of failure of the operation 
which had been done, was owing, probably, to a high division 
of the femoral arterv into two branches, and tied the vessel 
low down in the thigh. Immediately upon tightening the 
ligature, the pulsation in the tumor ceased, but in a few 
minutes became again as distinct as before the operation. A 
slight degree of compression was made over the sac. On the 



302 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



following day the pulsation was less perceptible, and two days 
afterwards it had entirely ceased. Daring the ten following 
days the sac had become firm. In the nineteenth case, No. 
200, the patient had been operated upon for a popliteal aneu- 
rism of the opposite side, three years previously, and was 
apparently cured, but when he presented himself for the 
second operation, a pulsating tumor of the size of a hen's 
egg was found in the ham. Upon examination of the femoral 
artery of this side, after the death of the patient, it was found 
to be obliterated for the space of two inches. 

In addition to these cases, an instance is mentioned bv Sir 

7 J 

A. Cooper, where an operation for popliteal aneurism was 
done by Mr. Key, and the disease apparently cured, but a year 
afterwards the patient returned to Guy's Hospital with the 
aneurismal tumor nearly of its original size, and he amputated 
the limb. 

Hemorrhage after the operation. — This occurred in twenty- 
four cases, of which twelve died and twelve were cured, one 
of the latter being with the loss of a limb. In No. 2, there was 
hemorrhage from the wound on the nineteenth and twentieth 
days after the operation, on the last occurrence of which the 
artery "was tied a little higher up." On the twenty-sixth 
day it recurred, and he patient died. In No. 7, death took 
place from hemorrhage on the eleventh day. In No. 28, the 
operation was done on the 14th of July. On the 24th there 
was slight hemorrhage from the wound, and on the 26th a 
return of it, which was arrested by compression. On the 6th 
of August there was another bleeding, which was again 
arrested by pressure, and the case did well. In No. 25, bleed- 
ing had taken place on the eleventh day, and returned violently 
on the twelfth, and carried off the patient. In No. 29, hemor- 
rhage took place on the forty-second day after the operation ; 
it again occurred on the following morning, and an hour after- 
wards the man died. In No. 34, there was bleeding from the 
wound on the fifth day after the ligature separated, and the 
patient did well. In No. Ill, there was hemorrhage on the 
fifteenth day, when the limb was amputated, and the patient 
recovered. In No. 38, the patient died from hemorrhage on 



1 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 303 

the twenty-seventh day. In No. 40, there was bleeding on 
the twenty-third day; this recurred on the twenty-fourth, 
when the wound was enlarged and stuffed with lint. The 
patient was cured. In No. 56, an attempt to remove the liga- 
ture was made three days after the operation ; two days subse- 
quent to this, in consequence of loss of blood, a second ligature 
was placed higher up on the artery, and within a few days 
there was another gush, and the man died. In Nos. 64 and 
74, death also took place from hemorrhage. In No. 68, there 
was hemorrhage from the wound on the sixteenth day, and a 
recurrence of it on the twenty-second, but the patient recov- 
ered. In No. 71, there was some hemorrhage eight days after 
the separation of the ligature, but it did not again recur, and 
the patient did well. In No. 92, a small non-pulsating tumor 
was observed soon after the operation, about the middle of 
the wound, and the same night an alarming loss of blood from 
the part took place ; the artery was now again secured higher 
up, and the patient recovered. In No. 100, there was hemor- 
rhage to eight ounces on the nineteenth day, and no bad 
result followed. In No. 96, hemorrhage took place on the 
separation of the ligature, on the eleventh day, to the amount 
of a pint and a half, and the patient recovered. In No. 107, 
there was slight hemorrhage from the wound on the seventh 
day, and the patient afterwards died of gangrene of the limb. 
In No. 122, a cure took place, despite copious hemorrhages on 
the eighth and thirteenth days. In No. 136, bleeding to a 
large amount took place on the fifth day, and on the following 
one it recurred, and he died. In No. 129, there was slight 
hemorrhage on the twelfth day from around the ligature; 
this returned on the same evening, and a tumor was observed 
at the point of the ligature which pulsated, and had attained 
the size of an orange. On the following day hemorrhage 
again took place, when the artery was tied above the pro- 
funda, and the tumor on the thigh laid open. On the eighth 
day following this there was another profuse bleeding, which 
was arrested by compresses and a bandage, and the patient 
recovered. In No. 130, which was a femoral aneurism, a 
popliteal tumor of the size of an orange had existed in the 



304 CONTRIBUTIONS TO PRACTICAL SURGERY. 

same limb, in which a spontaneous cure had taken place 
after the formation of that in the thigh. The ligature was 
applied just below Poupart's ligament. On the eleventh day 
after the operation, hemorrhage to the amount of two pounds 
took place from the wound, which was stopped by compresses 
and a spica bandage. On the thirteenth, fifteenth, and seven- 
teenth days, there were returns of the bleeding, but the patient 
recovered. In No. 193, the femoral was secured, July 7th, on 
account of a wound of the anterior tibial and interosseal 
arteries. On the 22d, there was hemorrhage to the extent of 
thirty-three ounces from the seat of operation, which was 
arrested by the application of cold and a tourniquet. On the 
24th, in consequence of a renewal of it, the external iliac was 
tied. On the 26th, there was another alarming hemorrhage, 
when the saphena vein and a branch of the profunda were 
taken up. The patient died September 1st. In No. 200, 
there was a slight hemorrhage previous to death on the nine- 
teenth day. 

Suppuration of the sac. — This occurred, after the operation 
for aneurism, in sixteen cases ; and of these, six died and ten 
did well. In No. 3, it is stated that the sac opened after the 
operation, but healed up like any other sore. In No. 19, on 
the fifth day after the operation, fluctuation became evident 
and the tumor was laid open. The patient died. In No. 7, 
fluctuation in the sac was noticed on the ninth day. and on 
the eleventh it burst, and the patient died of hemorrhage. In 
No. 26, at the end of a month, fluctuation was perceived in 
the tumor, and it was laid open. The patient died. In No. 
31, the sac opened and discharged during the cure. In No. 
38, an eschar formed on the tumor, after the operation, which 
discharged fetid matter. Warm milk and water were thrown 
into the sac, and on the same evening there was profuse hemor- 
rhage from it. To arrest this, amputation of the limb was 
done, soon after which the patient died. In No. 52, the tumor 
sloughed, one month after the ligature, and the patient recov- 
ered. In No. 53, the operation was done in October, 1813, 
and in the autumn of the following year the sac suppurated, 
was opened, and cicatrized. In No. 69, the tumor suppurated, 



MORTALITY FOLLOWING LIGATURE OP ARTERIES. 305 

and was opened, on the fifteenth day after the operation, and 
the patient recovered. In No. 73, on the seventh day after 
the ligature of the vessel, the integuments covering the tumor 
were mortified, and an opening into it was made and its con- 
tents set free. The patient died. In No. 81, the skin over 
the sac, which was gangrenous at the time of the operation, 
sloughed on the fourth day. In No. 92, there was suppura- 
tion of the sac, which was opened and the patient cured. In 
No. Ill, the tumor, which had been punctured before the 
artery was tied, afterwards suppurated and discharged. The 
man was cured after amputation. In No. 155, the sac suppu- 
rated more than five months after the operation, when an 
incision was made into it and the patient cured. In No. 160, 
the tumor suppurated and discharged itself, and the patient 
recovered. In No. 181, heat of tumor was observed on the 
eighth day after the application of the ligature; three days 
after this fluctuation was evident, and an exit was given to 
the pus. The patient died. 

Gangrene of the limb. — This followed in thirty-one out of 
the two hundred and four cases contained in the tables, and it 
in no case occurred except where the operation was done for 
aneurisms. Of these thirty-one cases, Nos. 12, 19, 35, 58, 64, 
83, 84, 89, 91, 94, 107, 108, 109, 128, 177, and 181, sunk at 
various periods after the operation. In No. 16, the last 
phalanges of the toes sloughed, as also a spot on the inferior 
part of the leg, and a portion of the fifth metatarsal bone 
exfoliated. The patient recovered. In No. 36, the operation 
was done on the 24th of July; mortification followed on the 
third day after it ; amputation was done on the 16th of August, 
six days after which the patient died. In No. 85, the artery 
was tied on the 25th of January. On the 30th, symptoms of 
gangrene set in, and on the first of February, the thigh was 
successfully amputated immediately below where the artery 
was tied. The gangrene in this case is stated to have been 
caused by the employment of fomentations of hot salt, not- 
withstanding strict injunctions to the contrary. In Nos. 97 
and 98, the patient had aneurismal tumors in both hams ; the 
left artery was first tied, and gangrene of the foot followed it. 



306 CONTRIBUTIONS TO PRACTICAL SURGERY. 

The ligature on the right limb was done at the request of the 
patient; gangrene occurred in it also, and death followed. In 
No. 99, mortification took place on the ninth day; the limb 
was amputated on the thirty-fourth day, and the man died. 
In No. 114, the limb is stated to have been threatened with 
gangrene before the vessel was tied — it followed the operation, 
and the man was cured after amputation. In No. 131, the 
ligature was applied on the 5th of September ; profuse hemor- 
rhage occurred in opening the sheath of the vessels. Gan- 
grene immediately followed. Amputation above the knee was 
done on the 18th, and the patient recovered. In No. 145, 
amputation was done a week after the operation, in conse- 
quence of mortification, and was followed by death. In No. 
148, the operation was followed by gangrene of the limb, and 
the thigh was removed unsuccessfully. In No. 182, gangrene 
appeared on the third day; amputation was done, after a line 
of demarcation was formed, and the patient recovered. In 
No. 183, the limb was amputated on the 22d day, and was 
followed by death in three hours. In No. 195, the tumor had 
burst previous to the operation, which was done on the 1st of 
March ; gangrene of the foot and leg followed, and on the 8th 
the thigh was amputated, and the patient got well. In No. 
198, symptoms of mortification appeared on the third day, 
after which trismus set in and the man died. In No. 203, the 
operation was followed by gangrene of the foot and leg. The 
thigh was amputated during its progress, seven days after 
which death occurred from gangrene of the stump. 

Cause of death. — Of the two hundred and four cases con- 
tained in the tables, fifty died. Of these, twenty-three died 
from mortification of the limb; eight from hemorrhage; five 
from phlebitis ; three from tetanus ; two from hectic and 
diarrhoea ; one from thoracic inflammation and abscesses in 
the course of the artery ; one from sloughing of the sac ; one 
from the bursting of an aneurism of the aorta within the peri- 
cardium twelve weeks after the operation ; one from fever ; 
one from absorption of pus ; and in four the cause is not 
noted. 

Mistakes in diagnosis. — In four of the cases included in the 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 307 

tables, mistakes in diagnosis occurred. In No. S3, the precise 
nature of the tumor could not be ascertained, and it was 
punctured before the operation. In No. Ill, the tumor was 
mistaken for an abscess, and opened a week previous to the 
operation ; after bleeding three pints it ceased spontaneously. 
In No. 138, the tumor was of the size of a goose's egg, 
distinctly pulsated, and was said to have shown itself sud- 
denly, while walking, three weeks previously. Compression 
was at first attempted, and afterwards the artery was tied, not- 
withstanding which the swelling continued to increase. On 
post-mortem examination, it was found to consist partly of a 
fibrous tissue divided into lobes, and in part of a soft sub- 
stance containing cells filled with a serous fluid. The artery 
ran over the tumor between two of the sacs, and through 
these its pulsations had been so communicated as to give the 
sensation of the whole tumor pulsating. The right lung was 
converted into a brain-like mass. In No. 196, the patient was 
a black woman, in whom there existed great swelling of the 
whole limb, but particularly of the popliteal region. Suspect- 
ing deep suppuration, an incision, an inch in length, was made 
into it, from which nothing but a little serum, slightly colored 
with blood, escaped. The integuments in the popliteal region 
afterwards ulcerated, and some days subsequently there was 
a profuse hemorrhage from the part when the artery was tied. 
Two very instructive cases of mistake in the diagnosis of 
popliteal tumors have been published by Mr. Lawrence, of 
London, which I will here take the liberty of referring to. 
The first (Medico- Chirurgical Transactions, vol. viii. p. 497) was 
that of a large aneurism filling up the whole ham, and extend- 
ing on both sides of the femur towards the front of the limb. 
It had begun behind, and had existed for five months ; had a 
firm, fleshy feel, being a little softer at one of its anterior pro- 
tuberances than in other parts; was not tender on handling, 
but gave the patient great pain. The surgeons of St. Bartho- 
lomew's, in consultation, viewing it as a large and rapidly 
increasing tumor, recommended amputation, which Mr. L. 
did, having first plunged a lancet into the softest part of the 
swelling, to the whole depth of the blade, without giving 



308 CONTRIBUTIONS TO PRACTICAL SURGERY. 

issue to any fluid. Examination of the amputated limb showed 
the tumor to be a popliteal aneurism, containing an immense 
mass of firm bloody coagulum, and although the sac had been 
freely penetrated by the abscess lancet, no part of its contents 
escaped. The eminent surgeon who records this adds, that 
he "has stated the case to put others on their guard; and shall 
be happy if what he has said should, in any instance, prevent 
so serious mutilation as that which his patient suffered." 

The second case was that of a man, aged thirty, with a 
swollen and painful state of the right knee-joint, consequent 
upon a fall. Shortly after, a swelling arose immediately above 
the knee, and gradually extended around the back part and 
sides of the thigh. Near the tendon of the triceps a softening 
of the swelling indicated the probability of its containing 
matter, and a small incision was made into it, from which 
about four ounces of arterial blood flowed. On examining 
the swelling more closely, pulsation in it was now discovered, 
and it was agreed that sufficient ground existed for believing 
the tumor to be a popliteal aneurism, and accordingly the 
femoral was tied. The pulsation immediately ceased, and its 
size gradually diminished; but, after some time, it again 
enlarged, became painful, the skin covering it sloughed, and 
the slough extended into the tumor, and the man shortly after 
died. The tumor was found to consist of a soft fibrous and 
dense osseous tissue — the latter originating from the femur. 
The femoral and popliteal vessels were sound. 

Difficulties of, and accidents during, the operation. — In eleven 
of the two hundred and four ligations of the femoral artery, 
the crural vein was either included in the ligature, or wounded 
in the operation. In Nos. 2 and 90, the vein as well as the 
artery was tied. In Nos. 13, 73, 94, 107, and 159, the vein 
was wounded in the operations. In No. 74, the ligature was 
found to have passed through the vein. In No. 131, profuse 
hemorrhage occurred on opening the sheaths of the vessels. 
In No. 146, the vein was wounded during the operation ; the 
patient recovered and lived four and a half years after it. On 
dissection, it was found to be obliterated to the extent of three 
inches. In No. 161, the vein was pricked in the operation, and 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 309 

a small portion of it included in the ligature along with the 
artery. It may be well here to mention that a case occurred 
to Sir A. Cooper, where the patient placed himself upon the 
table, for the purpose of undergoing ligature of the femoral 
vessel for a popliteal aneurism, and died before the first in- 
cisions were concluded, in consequence of the bursting of an 
aneurism of the aorta. 

In the Southern Journal of Medicine and Surgery for May, 
1848, an interesting case of false aneurism in the thigh is 
related, in which an attempt was made to ligate the femoral 
artery at the crural arch. A ligature was passed around what 
was supposed, by all present, to be the artery, but on post- 
mortem examination it was found that it embraced a portion 
of a tendon, and that the femoral artery was not tied. The 
patient was so exhausted from previous hemorrhage, at the 
time of the operation, that no pulsation could be felt in either 
of the lower extremities. 

Aneurisms on both sides. — Of the cases of aneurism included 
in the tables, nine presented popliteal aneurisms on both sides. 
In Nos. 22 and 23, both aneurisms were observed when the 
patient presented himself to his surgeon. The left, at the time 
of the first operation, was small, and increased rapidly after 
the ligature of the first artery. In Nos. 60 and 61, the aneu- 
rism of the left side did not exist at the time of the operation 
upon the right. In Nos. 79 and 80, the tumor on the right 
side showed itself but a few weeks before the second opera- 
tion. In Nos. 97 and .98, the aneurisms were both large, 
and of seven months' standing; the right.artery was tied two 
months after that of the left. In Nos. 125 and 126, the aneu- 
risms occurred simultaneously, and had existed for fifteen 
years. In Nos. 129 and 130, there was incipient disease of 
the right ham at the date of the operation upon the left. In 
Nos. 167 and 168, the second tumor did not make its appear- 
ance till after the cure of the first. In Nos. 188 and 189, the 
disease seemed to be beginning on the right side at the time 
of the first operation. In Nos. 201 and 202, the tumor in the 
left ham was noticed some time after that of the right side had 
been operated upon. No. 84 was also a subject of aneurism in 






310 CONTRIBUTIONS TO PRACTICAL SURGERY. 

each ham. In No. 197, the tumor in the ham was first observed 
about ten days after a ligature had been placed on the external 
iliac of the opposite side for the cure of a femoral aneurism. 
No. 20 had been the subject of popliteal aneurisms of both 
sides, and the left limb was amputated some time previous to 
the ligature of the vessel of the right side. In No. 200, also, 
the artery on the left side had been tied three years pre- 
viously for a popliteal aneurism. 

Pulsating tumors of the head of the tibia, or condyle of the 
femur. — Four cases are included in the tables in which the 
femoral artery was ligatured for the cure of these affections. 
They all recovered ; but in two of them, although cures ap- 
peared to follow, there were afterwards returns of the disease. 
In No. 68, the limb was amputated between three and four 
years after the ligature had been applied, the tumor having 
attained a great size. In another, which occurred to the 
writer, although the ligature of the vessel was apparently 
followed by a cure of the disease, the tumor returned, and, 
eleven months after it, I amputated the limb. In three of 
the cases in which the vessel was tied for these tumors (Nos. 
68, 151, and 187), pulsation reappeared ; in the first on the 
sixteenth day, but soon ceased ; in the second on the seven- 
teenth day, and ceased on the twenty-sixth day ; and in the 
third on the seventh day. 

Varicose aneurisms. — The foregoing tables contain five 
cases of varicose aneurisms of the lower limb. Four of these 
proved fatal, and in one no benefit was received from the 
operation. In No. 64, where the disease was situated on the 
posterior tibial artery, death occurred from gangrene of the 
limb and hemorrhages. In No. 94, where the femoral was 
affected, the operation was soon followed by gangrene and 
death. In No. 96, the disease was situated in the middle of 
the thigh, and the ligature was placed as nearly as practica- 
ble to the sac. The case went on favorably till the separation 
of the ligature on the eleventh day, when the patient came 
near losing his life from hemorrhage, and was in no way 
benefited by the operation. The contents of the tumor never 
coagulated, nor did the tumor decrease, and in the following 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 311 

year it remained stationary, with as much pulsation as before. 
In No. 136, death soon followed the ligature of the artery, 
and, on dissection, the vessel was found to be enlarged nearly 
to the size of the aorta, with its coats so thin as to give it 
nearly the appearance of a vein. In No. 148, the artery was 
tied immediately below Poupart's ligament. It was followed 
by mortification of the limb, and the thigh was removed six 
inches below the hip-joint. There was afterwards a return 
of the disease, and secondary hemorrhage terminated life. 

In connection with the above instances of varicose aneurism, 
in which the femoral artery has been tied, it may be inter- 
esting to contrast their results with those in which either the 
external iliac has been secured, or other treatment has been 
adopted, for the same affection. In the case of Baroni, where 
the disease was seated in the inguinal region, and the external 
iliac was taken up, an incision was made into the sac on the 
forty-fifth day, in consequence of repeated bleedings, with 
the view of securing all the vessels. The hemorrhage was 
so frightful, that the patient was only saved from dying on 
the table by making strong compression, and death occurred 
eleven days after. In Dr. Fleischer's patient, where the af- 
fection occupied the middle of the thigh, and an incision into 
the sac was made, the fatal result took place from like causes. 
In the history reported by Hennen, where the external iliac 
was tied, the affection being seated in the upper third of the 
thigh, gangrene and death speedily followed ; and in the case 
of Dr. Morrison, ligature of the external iliac was also made 
for a like affection, seated at the same part, and death in a 
short time terminated the sufferings of the patient. In the 
instance reported by Lallemand, where the disease was seated 
above the middle of the thigh, and was of five years' con- 
tinuance, the femoral artery was first tied a little below Pou- 
part's ligament. On the sixth day, in consequence of hemor- 
rhage, the external iliac was ligatured, and on the same evening 
the bleeding again recurred, and he died. In a case recently 
published by Dr. Mott, the disease occupied the upper part 
of the thigh, and had existed for two and a half years. A 



312 CONTRIBUTIONS TO PRACTICAL SURGERY. 

ligature was applied to the external iliac ; gangrene super- 
vened, and the man died on the sixth day. 

Observation, however, shows that varicose aneurisms in 
the lower extremity, after a certain lapse of time, in several 
cases have become stationary ; and instances are recorded in 
which the affection has continued for years, causing but little 
inconvenience. In 1820, a patient fell under the notice of 
M. Dupuytren, with a large varicose aneurism of the upper 
part of the thigh, which had continued for twelve years with- 
out injuring the health, or in any way interfering with the 
free use of the limb ; and in the spring of 1835, a patient was 
in the wards of M. Velpeau, at La Charite, in whom a like 
affection, seated high up in the thigh, had existed for more 
than twenty years, without materially interfering with the 
use of his member. A few years since, I had an opportunity 
of examining, along with several other surgeons of this city, 
a case of long continuance, which inconvenienced, though it 
did not distress, the patient. In face of these facts it is, in my 
opinion, no longer a question whether or not operative mea- 
sures should be resorted to in the lower limb in the treatment 
of such cases. Sound surgery condemns it. The affection 
does not necessarily compromise life, or the free use of the 
member ; and resort to the knife should not be had so long as 
the infirmity can be made at all bearable by the use of com- 
presses, laced bandages, and other like means. If in any case 
an operation for varicose aneurism in the lower extremity is 
absolutely demanded, all reasoning, as well as experience on 
the subject, goes to show that no good result can be expected 
from the application of a ligature by Hunter's method. 

The following is a summary of the reported cases of femoral 
and popliteal aneurisms which have been treated by pressure 
since 1842. They have, with two or three exceptions, been 
derived from Mr. Bellingham's Tract on Aneurism, and the 
Eeport on Surgery, contained in the first volume of the Trans- 
actions of the American Medical Association. 



MORTALITY FOLLOWING LIGATURE OF ARTERIES. 



313 



Surgeon. 



Hutton 

Cusack 

Bellingham 

Liston 

Harrison 

Liston 

Bellingham 

Kirby 

Allan 

Greatrex 

Cusack 

Porter 

Cusack 



Porter 

O'Ferral 

Jolley 

Macdonnell 

Dartnell 

Mackera 

Stork 

Stork 
Cusack 
Sunter 
Bellingham 



St. Vincent's 
Hospital 
Armstrong 1 
Harrison 



Humphrey 
Buck 



Rodgers 
Watson 
MQ tter 
Knights 

Hosack 



Tufnell 
Tufnell 
Hutton 



Sex. 



Male 
Male 
Male 

Male 
Male 
Male 
Male 
Male 
Male 
Male 
Male 
Male 



Male 
Male 
Male 

Male 
Male 
Male 

Male 
Male 
Male 
Male 



Male 
Male 



Male 



Male 
Female 
Male 
Male 

Male 



Male 
Male 
Male 



31 



Seat of 
aneurism. 



Popliteal 

Popliteal 

Popliteal 

Femoral 

Popliteal 

Femoral 

Femoral 

Popliteal 

Popliteal 

Popliteal 

Popliteal 

Popliteal 

Popliteal 



Popliteal 

Popliteal 

Popliteal 

Popliteal 

Popliteal 

Femoral 

Popliteal 

Popliteal 
Popliteal 
Popliteal 
Popliteal 



Popliteal 

Popliteal 
Popliteal 



Femoral 
Femoral 



Popliteal 
Femoral 
Popliteal 
Popliteal 

Popliteal 



Popliteal 
Popliteal 
Popliteal 



10 days 
7 days 
3 months 
2 months 
month 

2 months 
10 days 

3 months 
3 weeks 

1 month 

2 months 



Duration of 
disease. 



9 months 

3 weeks 

4 months 

6 months 
3 weeks 
9 months 

7 or 8 
months 

2 months 
16 days 
6 weeks 

8 months 



Some 
months 



3 weeks 



2 months 
1 month 
6 weeks 
Several 
months 



4 months 
A few days 
2 months 



Duration of 
compression. 



28 days 
31 days 
2 days 

56 days 
93 days 
30 days 
43 days 
53 days 

57 days 
21 days 
7 days 
24 days 
About 20 days 



20 days 
33 days 
40 days 



Result. 



7 days 
36 days 
91 days 

22 days 

43 days 

Several days 

Pulsation continuing 
some time after com- 
pression, a galvanic 
current was passed 
through the sac. Se- 
ven days after this 
he was seized with 
erysipelas, and died 
six days afterwards. 



106 days 

A fortnight, when 
the operation was 
performed at the re- 
quest of the patient. 

2 days 

Fairly tried 



31 days 
70 hours 
54 days 
40 houi'S 

5 days. After a fort- 
night, a slight thrill 
being detected in 
the tumor, it was re- 
applied for 36 hours 

9 days 

46 days 

7i hours, and after an 
interval of a week 3 
hours longer 



Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Died suddenly 
from disease 
of the heart 
48 hours after 
pressure had 
been removed. 
All pulsation 
had ceased. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 
Cured. 
Cured. 



Cured. 
Cured. 



Cured. 

Failure and the 
operation per- 
formed. 

Cured. 

Cured. 

Cured. 

Cured. 

Cured. 



Cured. 
Cured. 
Cured. 



1 In this case, pressure was made upon the tumor, not upon the artery above it. 
£ In this case, manual pressure, by relays of assistants, alone was used. 



21 



314 CONTRIBUTIONS TO PRACTICAL SURGERY. 



VARICOSE ANEURISM AT THE BEND OF THE ARM. 

Varicose aneurism at the tend of the arm; ligature of the 
artery above and below the sac; secondary hemorrhages with a 
return of the aneurismal thrill on the 10th day ; cure. — In May, 
1842, I saw in consultation with Dr. Butter, Mr. K., aetat. 42, 
on account of a tumor at the bend of the arm, which had 
followed venesection. The patient, who had a permanent jaun- 
diced appearance, but was enjoying an apparently good state 
of health, gave the following account of it: In March he 
was bled at his desire by a bleeder who had performed the 
same operation for him, and generally in the same arm, some 
thirty or forty times. Nothing extraordinary occurred, other 
than that he remarked the flow of blood to be greater, and to 
be checked with more difficulty than had usually been the 
case. This was, however, done by firm compression, and on 
the day following finding the bandage tight, he removed it, 
and found the orifice to be completely closed. A short time 
after this, a small pulsating swelling was observed by him at 
this point, which slowly increased till a day or two previous 
to my seeing him, when, after some exertion with his arm, he 
observed a very considerable sudden augmentation in its size. 
Upon examination, a tumor of the size of a walnut was found 
at the bend of the arm ; this was soft, pulsated strongly, and 
offered both to the touch and ear the purr and thrill peculiar to 
varicose aneurism. The vein running over the surface of the 
tumor was greatly enlarged, and in its centre a cicatrix was 
perceptible, the skin around it appearing to be exceedingly thin. 
By pressure the vein could be readily emptied, and when this 
was done, a pulsating tumor was plainly felt more deeply 
situated between it and the brachial artery, which by firm 
pressure could likewise be made to disappear. Compression 
on the artery above the tumor stopped all pulsation in it, on 



VARICOSE ANEURISM AT THE BEND OP THE ARM. 315 

the removal of which it quickly returned to its original size. 
The pulse at the wrist was weaker than that of the opposite 
arm. 

As the case was evidently one of false circumscribed aneu- 
rism, combined with aneurismal varix, and was increasing, I 
recommended him to undergo an operation for its cure, in 
which opinion Dr, J. R. Barton, who afterwards examined it, 
coincided. To this, however, the patient was averse, and I 
heard nothing more of him till the 16th of June, when I was 
again consulted, and found that he had been making use of 
strong and well-applied pressure by means of a spring truss 
from the time I first saw him, and finding this painful and 
the tumor still augmenting, was now anxious to undergo the 
operation. 

This was done on the 17th. The artery being compressed 
in the arm, the skin was divided over the tumor in its whole 
extent, without, however, opening the vein. The sac and 
dilated vein were then fully exposed by dissection as well as 
the artery, and ligatures were passed under the latter imme- 
diately above and below the sac. After careful examination 
to see that the ligatures surrounded the artery alone, these 
were secured — the lower one first. All pulsation in the part 
immediately ceased. The edges of the wound were drawn 
into apposition by adhesive plaster, and the patient was put 
to bed with the limb extended on a pillow. 

On the 20th, pulsation could be felt in the radial artery. 

On the 27th, a return of the thrill in the vein was detected. 

Early on the morning of the 29th, he was awoke out of a 
sound sleep by hemorrhage from the arm, which, when I 
reached him a half hour after its occurrence, had been 
checked by a professional gentleman in the neighborhood by 
the application of a moderate degree of pressure ; near a pint 
of florid blood was said to have been lost. Finding him easy, 
I left him without in any way disturbing the wound, but 
before mid-day was again summoned on account of a renewal 
of the bleeding. Upon removing the dressings, this was found 
to proceed from the opening through which the upper liga- 
ture passed. The parts around the wound presented a good 



316 CONTRIBUTIONS TO PRACTICAL SURGERY. 

appearance, no inflammation existing, and the divided parts 
having entirely united except at the points through which 
the ligature passed, neither of which were yet loose. Accu- 
rate examination of the brachial artery showed the extremity 
of the vessel above the upper ligature to be hard, and com- 
pletely filled with coagulum, and this, in connection with the 
return of the thrill in the vein, which was now nearly as 
strong as it had originally been, and the direction from which 
the blood seemed to flow, led both my friend, Dr. B. Peace, 
who was present with me, and myself, to look upon the 
hemorrhage as proceeding from some opening in the upper 
part of the sac, and it was determined to lay open the vein 
and sac, first passing ligatures under the vein above and below, 
and afterwards tie up any vessels which should be found to 
give out blood. This was at once done, and a vessel from 
which arterial blood was poured out was secured at the bottom 
of the sac. 

This proceeding was painful, but gave rise to no undue 
inflammation or fever. On the 3d of Julv, the ligature on 
the lower end of the artery (below the sac) was found to be 
loose and was removed. On the 7th, there was a return of 
the hemorrhage to the amount of several ounces, which was 
checked bj lint and compression, and during the night other 
recurrences of bleeding took place which were each time 
restrained by pressure. On the 8th there was a renewal of 
the bleeding to such an extent as to necessitate the applica- 
tion of the tourniquet. All dressings were now removed pre- 
paratory to securing the artery high up in the arm, but the 
hemorrhage was found to have entirely ceased. It was now 
concluded to apply pure creasote freely to the wound, which 
was done by means of a camel's hair brush, and lint saturated 
with this substance was afterwards placed over the part with- 
out any other dressing, the extremity being extended on a 
pillow; the upper ligature was seen to be loose and was 
removed. On the 12th, the lint having become loosened by 
suppuration, was removed, and dry lint applied, which was 
changed every second day till the 25th, when cicatrization 
had taken place. 



VARICOSE ANEURISM AT THE BEND OF THE ARM. 317 

In the beginning of the month of October, I saw Mr. K., 
and found no trace of pulsation or tumor at the bend of the 
arm — the extremity had regained all its former power. 

The preceding is an example of the affection first accurately 
described by Park and Physick, in which a false circum- 
scribed aneurism exists in connection with aneurismal varix. 
The course of treatment to be pursued in either form of aneu- 
rismal varix does not seem to be yet determined by surgeons; 
some recommending simple ligature of the vessel above and 
below the sac without an opening into it, some the Hunterian 
method, some the ancient operation for aneurism, while others 
are inclined to rely upon compression alone. 

Despite the superficial situation of the vessel, but few ex- 
amples of the cure of false aneurisms at the bend of the arm 
by the latter method (compression) can be cited, except it be 
made immediately after the occurrence of the accident, when, 
if applied with judgment, it will generally prove successful. 
The mere application of pressure over or above the wound, 
in the way it is commonly made after venesection, will, how- 
ever, almost invariably fail. Where the artery is wounded 
and compression is resorted to, a folded piece of lint should 
be placed over the wound, and a roller well and evenly 
applied to the member from the fingers to the shoulder, which 
will prevent the oedema and great pain so often resulting 
from the application of pressure at the point of injury alone. 
The limb after the bandaging should be kept in a state of per- 
fect rest by means of an angular splint applied on the side of 
the arm, for a week or ten days after the accident, during the 
whole of which time the patient should be closely watched, 
and the bandage renewed as often as may be necessary. 

Where, however, some time has elapsed after the produc- 
tion of the aneurism, compression is little to be relied on in 
its results, severe pain, excoriation, and even gangrene of the 
sac, having all repeatedly occurred from its application. Ex- 
cept when very recent, too, the Hunterian method is now 
commonly looked upon as inapplicable in these cases, and is 
abandoned, general experience proving that it fails where the 
affection is of any standing. The old operation of laying 



318 



CONTRIBUTIONS TO PRACTICAL SURGERY. 



open the sac and securing the vessel above and below the 
wounded point, is still recommended by many estimable 
authors, is often performed, and, I believe, when the disease 
is of long standing, or of large size, is always the best and 
safest operation. In the case related, ligature of the vessel 
above and below the tumor, without meddling with its con- 
tents, was resorted to, inasmuch as the disease was only 
moderately developed, in order to avoid the increased danger 
attendant upon incision of the sac. The accidents to which 
the method exposes are well exemplified by the above case, 
and were such as will prevent my ever again having recourse 
to it, in other than the cases specified. In all the operations 
for varicose aneurism it is better, if possible, to avoid division 
of the vein ; sometimes, however, this is impossible, and 
where divided, a thin ligature should be applied to it. 






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